Description
Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive psychiatric evaluation notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you examined at your practicum site, using the Comprehensive Psychiatric Evaluation Note Template provided. You will then use this note to develop and record a case presentation for this patient.
Review this week’s Learning Resources and consider the insights they provide about impulse-control and conduct disorders.
Select a patient for whom you conducted psychotherapy for an impulse control or conduct disorderduring the last 6 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide. All psychiatric evaluation notes must be signed by your Preceptor. When you submit your note, you should include the complete comprehensive evaluation note as a Word document and pdf/images of the completed assignment signed by your Preceptor. You must submit your note using Turnitin.
Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Grading Policy.
Then, based on your evaluation of this patient, develop a video presentation of the case. Plan your presentation using the Assignment rubric and rehearse what you plan to say. Be sure to review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
Include at least five scholarly resources to support your assessment and diagnostic reasoning.
Ensure that you have the appropriate lighting and equipment to record the presentation.
Record yourself presenting the complex case for your clinical patient.
Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video.
In your presentation:
Dress professionally and present yourself in a professional manner.
Display your photo ID at the start of the video when you introduce yourself.
Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
Present the full complex case study. Be succinct in your presentation, and do not exceed 8 minutes. Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.
Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What was the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective: What observations did you make during the psychiatric assessment?
Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms.
Plan: Describe your treatment modality and your plan for psychotherapy. Explain the principles of psychotherapy that underline your chosen treatment plan to support your rationale for the chosen psychotherapy framework. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this psychotherapy session?
Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
31 year old female patient comes to the clinic seeking help due to difficulties controlling her impulses, which are negatively impacting her personal and professional life. She describes impulsive behaviors such as excessive shopping, binge eating, and difficulty managing her temper. Pt shares her struggles with impulsive behaviors, emphasizing the negative consequences they have had on her life. She acknowledges feeling a lack of control over her impulses and a growing sense of distress.Pt will work on specific behavioral interventions targeting impulsive behaviors. This may involve developing strategies to resist the urge to engage in impulsive shopping or learning techniques to manage anger and frustration more effectively.Provider incorporates mindfulness techniques to help patient become more aware of her thoughts and emotions in the present moment. Will continue working with patient the following week
.( just the follow the template )
Unformatted Attachment Preview
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6645: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date
NRNP/PRAC 6645 Comprehensive Psychiatric
Evaluation Note Template
CC (chief complaint):
HPI:
Past Psychiatric History:
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General Statement:
Caregivers (if applicable):
Hospitalizations:
Medication trials:
Psychotherapy or Previous Psychiatric Diagnosis:
Substance Current Use and History:
Family Psychiatric/Substance Use History:
Psychosocial History:
Medical History:
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Current Medications:
Allergies:
Reproductive Hx:
ROS:
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GENERAL:
HEENT:
SKIN:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
GENITOURINARY:
NEUROLOGICAL:
MUSCULOSKELETAL:
HEMATOLOGIC:
LYMPHATICS:
ENDOCRINOLOGIC:
Physical exam: if applicable
Diagnostic results:
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Assessment
Mental Status Examination:
Differential Diagnoses:
Case Formulation and Treatment Plan:
Reflections:
References
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NRNP/PRAC 6645 Comprehensive Psychiatric
Evaluation Note Template
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ
CAREFULLY
If you are struggling with the format or remembering what to include, follow the
Comprehensive Psychiatric Evaluation Template AND the Rubric as your guide. It is
also helpful to review the rubric in detail in order not to lose points unnecessarily
because you missed something required. Below highlights by category are taken
directly from the grading rubric for the assignments. After reviewing full details of the
rubric, you can use it as a guide.
In the Subjective section, provide:
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Chief complaint
History of present illness (HPI)
Past psychiatric history
Medication trials and current medications
Psychotherapy or previous psychiatric diagnosis
Pertinent substance use, family psychiatric/substance use, social, and
medical history
Allergies
ROS
Read rating descriptions to see the grading standards!
In the Objective section, provide:
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Physical exam documentation of systems pertinent to the chief complaint,
HPI, and history
Diagnostic results, including any labs, imaging, or other assessments needed
to develop the differential diagnoses.
Read rating descriptions to see the grading standards!
In the Assessment section, provide:
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Results of the mental status examination, presented in paragraph form.
At least three differentials with supporting evidence. List them from top priority
to least priority. Compare the DSM-5 diagnostic criteria for each differential
diagnosis and explain what DSM-5 criteria rules out the differential diagnosis
to find an accurate diagnosis. Explain the critical-thinking process that led you
to the primary diagnosis you selected. Include pertinent positives and
pertinent negatives for the specific patient case.
Read rating descriptions to see the grading standards!
Reflect on this case. Include what you learned and what you might do differently. Also
include in your reflection a discussion related to legal/ethical considerations
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NRNP/PRAC 6645 Comprehensive Psychiatric
Evaluation Note Template
(demonstrate critical thinking beyond confidentiality and consent for treatment!),
health promotion and disease prevention taking into consideration patient factors (such
as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural
background, etc.).
(The comprehensive evaluation is typically the initial new patient evaluation. You will
practice writing this type of note in this course. You will be ruling out other mental
illnesses so often you will write up what symptoms are present and what symptoms are
not present from illnesses to demonstrate you have indeed assessed for all illnesses
which could be impacting your patient. For example, anxiety symptoms, depressive
symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)
EXEMPLAR BEGINS HERE
CC (chief complaint): A brief statement identifying why the patient is here. This
statement is verbatim of the patient’s own words about why they are presenting for
assessment. For a patient with dementia or other cognitive deficits, this statement can
be obtained from a family member.
HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation,
current medication, and referral reason. For example:
N.M. is a 34-year-old Asian male who presents for psychotherapeutic evaluation for
anxiety. He is currently prescribed sertraline by (?) which he finds ineffective. His PCP
referred him for evaluation and treatment.
Or
P.H. is a 16-year-old Hispanic female who presents for psychotherapeutic evaluation for
concentration difficulty. She is not currently prescribed psychotropic medications. She is
referred by her mental health provider for evaluation and treatment.
Then, this section continues with the symptom analysis for your note. Thorough
documentation in this section is essential for patient care, coding, and billing analysis.
Paint a picture of what is wrong with the patient. This section contains the symptoms
that is bringing the patient into your office. The symptoms onset, the duration, the
frequency, the severity, and the impact. Your description here will guide your differential
diagnoses. You are seeking symptoms that may align with many DSM-5 diagnoses,
narrowing to what aligns with diagnostic criteria for mental health and substance use
disorders. You will complete a psychiatric ROS to rule out other psychiatric illnesses.
Past Psychiatric History: This section documents the patient’s past treatments. Use
the mnemonic Go Cha MP.
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NRNP/PRAC 6645 Comprehensive Psychiatric
Evaluation Note Template
General Statement: Typically, this is a statement of the patients first treatment
experience. For example: The patient entered treatment at the age of 10 with
counseling for depression during her parents’ divorce. OR The patient entered
treatment for detox at age 26 after abusing alcohol since age 13.
Caregivers are listed if applicable.
Hospitalizations: How many hospitalizations? When and where was last hospitalization?
How many detox? How many residential treatments? When and where was last
detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history
of self-harm behaviors?
Medication trials: What are the previous psychotropic medications the patient has tried
and what was their reaction? Effective, Not Effective, Adverse Reaction? Some
examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine
(effective, insurance wouldn’t pay for it)
Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of
two ways depending on what you want to capture to support the evaluation. First, does
the patient know what type? Did they find psychotherapy helpful or not? Why? Second,
what are the previous diagnosis for the client noted from previous treatments and other
providers. (Or, you could document both.)
Substance Use History: This section contains any history or current use of caffeine,
nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of
use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any
histories of withdrawal complications from tremors, Delirium Tremens, or seizures.
Family Psychiatric/Substance Use History: This section contains any family history
of psychiatric illness, substance use illnesses, and family suicides. You may choose to
use a genogram to depict this information (be sure to include a reader’s key to your
genogram) or write up in narrative form.
Psychosocial History: This section may be lengthy if completing an evaluation for
psychotherapy or shorter if completing an evaluation for psychopharmacology.
However, at a minimum, please include:
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Where patient was born, who raised the patient
Number of brothers/sisters (what order is the patient within siblings)
Who the patient currently lives with in a home? Are they single, married,
divorced, widowed? How many children?
Educational Level
Hobbies
Work History: currently working/profession, disabled, unemployed, retired?
Legal history: past hx, any current issues?
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NRNP/PRAC 6645 Comprehensive Psychiatric
Evaluation Note Template
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Trauma history: Any childhood or adult history of trauma?
Violence Hx: Concern or issues about safety (personal, home, community,
sexual (current & historical)
Medical History: This section contains any illnesses, surgeries, include any hx of
seizures, head injuries.
Current Medications: Include dosage, frequency, length of time used, and reason for
use. Also include OTC or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately. Provide a
description of what the allergy is (e.g., angioedema, anaphylaxis). This will help
determine a true reaction vs. intolerance.
Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no),
Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse:
oral, anal, vaginal, other, any sexual concerns
Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to
develop the differential diagnoses (support with evidenced and guidelines).
Assessment
Mental Status Examination: For the purposes of your courses, this section must be
presented in paragraph form and not use of a checklist! This section you will describe
the patient’s appearance, attitude, behavior, mood and affect, speech, thought
processes, thought content, perceptions (hallucinations, pseudo hallucinations, illusions,
etc.), cognition, insight, judgment, and SI/HI. See an example below. You will modify to
include the specifics for your patient on the above elements—DO NOT just copy the
example. You may use a preceptor’s way of organizing the information if the MSE is in
paragraph form.
He is an 8 yo African American male who looks his stated age. He is cooperative with
examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence
of any abnormal motor activity. His speech is clear, coherent, normal in volume and
tone. His thought process is goal directed and logical. There is no evidence of
looseness of association or flight of ideas. His mood is euthymic, and his affect
appropriate to his mood. He was smiling at times in an appropriate manner. He denies
any auditory or visual hallucinations. There is no evidence of any delusional thinking.
He denies any current suicidal or homicidal ideation. Cognitively, he is alert and
oriented. His recent and remote memory is intact. His concentration is good. His insight
is good.
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NRNP/PRAC 6645 Comprehensive Psychiatric
Evaluation Note Template
Differential Diagnoses: You must have at least three differentials with supporting
evidence. Explain what rules each differential in or out and justify your primary
diagnosis selection. Include pertinent positives and pertinent negatives for the specific
patient case.
Also included in this section is the reflection. Reflect on this case and discuss whether or not
you agree with your preceptor’s assessment and diagnostic impression of the patient and why or
why not. What did you learn from this case? What would you do differently?
Also include in your reflection a discussion related to legal/ethical considerations
(demonstrating critical thinking beyond confidentiality and consent for treatment!), social
determinates of health, health promotion and disease prevention taking into consideration patient
factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic,
cultural background, etc.).
Case Formulation and Treatment Plan.
Includes documentation of diagnostic studies that will be obtained, referrals to other
health care providers, therapeutic interventions with psychotherapy, education,
disposition of the patient, and any planned follow-up visits. Each diagnosis or condition
documented in the assessment should be addressed in the plan. The details of the plan
should follow an orderly manner. *see an example below—you will modify to your
practice so there may be information excluded/included—what does your
preceptor document?
Example:
Initiation of (what form/type) of individual, group, or family psychotherapy and
frequency.
Documentation of any resources you provide for patient education or coping/relaxation
skills, homework for next appointment.
Client has emergency numbers: Emergency Services 911, the Client’s Crisis Line 1800-_______. Client instructed to go to nearest ER or call 911 if they become actively
suicidal and/or homicidal. (only if you or preceptor provided them)
Reviewed hospital records/therapist records for collaborative information; Reviewed
PCP report (only if actually available)
Time allowed for questions and answers provided. Provided supportive listening. Client
appeared to understand discussion. Client is amenable with this plan and agrees to
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NRNP/PRAC 6645 Comprehensive Psychiatric
Evaluation Note Template
follow treatment regimen as discussed. (This relates to informed consent; you will need
to assess their understanding and agreement.)
Follow up with PCP as needed and/or for:
Write out what psychotherapy testing or screening ordered/conducted, rationale for
ordering
Any other community or provider referrals
Return to clinic:
Continued treatment is medically necessary to address chronic symptoms, improve
functioning, and prevent the need for a higher level of care OR if one-time evaluation,
say so and any other follow up plans.
References (move to begin on next page)
You are required to include at least three evidence-based, peer-reviewed journal
articles or evidenced-based guidelines which relate to this case to support your
diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition
formatting.
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