Description
RE: Comprehensive Psychiatric Evaluation #3, Objective Report
In this assignment we are given door information #3 to write a comprehensive psychiatric evaluation objective medical report.In this hypothetical, the hypothetical door information is all we would get right before entering the clinical room and seeing the patient, everything else would have to be obtained from the patient and properly cited using patient quotes or appropriate references, for example.For the comprehensive psychiatric evaluation #3, we can make up our own hypothetical door information that aligns with our ideal patient/clinical scenario. Do not use anxiety as the patient´s psychiatric disorder as I have already used anxiety in the past per the attached sample.We can make up the patient´s chief complaint to be characteristic of ADHD and other psychiatric mental health condition with the appropriate evidence throughout, of course.For information not provided in the door information, we can make it up to come up with our ideal clinical scenario/patient.However, information documented should align with the door information and be supported by evidence such as patient detailed info provided during a detailed and comprehensive clinical evaluation and interview that asks a series of several detailed questions such as onset of condition, stress factors, trouble sleeping, etc
In the future, following the same instructions and using faculty feedback, we will work on future medical reports.
I already completed clinical medical report #1 and received faculty feedback in PDF format, 90/100, with instructor feedback in the PDF document titled medical report #1 instructor feedbackalong with the rubric filled out below and attached as a separate document.
The medical info such as medications to prescribe should not be difficult to find using google and appropriate references. However, faculty as you will see from their feedback want detailed responses such as severity of onset, how long ago did it start, evidence from the patient´s own words that we can make up, etc.
If you need any additional info, feel free to ask along the way.
From previous instructor feedback, some comments are very helpful moving forward including writing the chief complaint as a quote in the patient´s words, etc.
As you will see, in my Comprehensive Psychiatric Evaluation #1 instructor feedback PDF, faculty want more detail narratives in some areas such as severity of onset, how long ago did it start, evidence from the patient´s own words that we can make up, what questions we would ask such as whether the patient has access to weapons at home?, and in other areas, more bulleted lists.Further, we can omit concluding statements while some details also have to be included in the History of Present IIllness, HPI section, for example.
Kindly use the rubric to include ALL SUPTOPICS AND DETAILS REQUESTED following the sample religiously.The sample medical report #1 attached as a word document should be of great help.Kindly use medical report #1 as a model for medical report #3.
According to the door information, we need to prescribe at least two medications and provide the psychopharmacology rationale for one scheduled and one prn medication.
Door information instructions regarding the two medications prescribed: Psychopharmacology rationale should include:A thorough explanation of all psychiatric medications prescribed or continued.This is including but not limited to the mechanism of action,the medication class,potential side effects, potential medication interactions if taking other medications, black box warnings, contraindications, and any prescribing considerations for these prescribed medications.Then provide a rationale on why you chose these specific medications for this patient.
Google may assist in determining which medications to prescribe to ADHD patients, for example, including dose mg, etc.
I am attaching clinical medical report #1 with instructor feedback included example titled:
Comprehensive Psychiatric Evaluation #1 earned 90 with instructor feedback
References should be used extensively and cited throughout the medical report with in-text citations in APA 7th Ed.I have provided references from the syllabus below and you can use these or other references no older than 5 years old, look at the examples for the types of references used).Stahl (2021) is highly recommended for prescriptions and American Psychiatric Association (2022) is highly recommended for diagnoses and criteria.You may access many of the references at libgen.is as needed or I can provide them to you upon request, but the problem is that the file sizes are large.
References
American Psychiatric Association (2022). Diagnostic and Statistical Manual of Mental
Disorders DSM 5-TR (5th ed. Text Revision). American Psychiatric Association: Arlington, Virginia. ISBN-10: 0890425760
Carlat, D. (2017). The Psychiatric Interview (4th Ed.). Lippincott Williams & Wilkins: Philadelphia, ISBN-13: 978-1496327710 ISBN-10: 9781496327710
Stahl, S.M. (2021). Stahl’s Essential Psychopharmacology Prescriber’s Guide (7th Ed.). Cambridge University Press: New York, NY. ISBN-13: 978-1108926010 ISBN-10: 1108926010
Zimmerman, M. (2013). Interview Guide for Evaluating DSM-5 Psychiatric Disorders and the Mental Status Examination. Psych Products Press: East Greenwich, RI. ISBN-13: 978-0963382115 ISBN-10: 096338211X
American Psychiatric Association (2022). Desk Reference to the Diagnostic Criteria from DSM- 5TR. Arlington, Virginia: APA ISBN-10 : 089042580 ISBN-13 : 978-0890425800
Boland, R., Verduin, M.L & Ruiz, P. (2022). Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (12th Ed,). Lippincott Williams & Wilkins: Philadelphia, PA. ISBN-13: 978-1975145569; ISBN-10: 1975145569
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental
Disorders DSM 5 (5th ed.).America Psychiatric Association: Arlington, Virginia
Boland, R., Verduin, M.L & Ruiz, P. (2022). Kaplan and Sadock’s Synopsis of Psychiatry:
Behavioral Sciences/Clinical Psychiatry (12th Ed,). Lippincott Williams & Wilkins:
Philadelphia, PA. ISBN-13: 978-1975145569; ISBN-10: 1975145569
Carlat, D. (2016). The Psychiatric Interview (4th Ed.). Lippincott Williams & Wilkins:
Philadelphia, PA. ISBN-13: 978-1496327710 ISBN-10: 9781496327710
Wheeler K. (2022). Psychotherapy for the Advanced Practice Psychiatric Nurse: A
How-To Guide for Evidence-Based Practice. 3rd Edition. Springer Publishing; New York,ISBN-13: 978-0826193797 ISBN-10: 082619379X
American Psychiatric Association (2013). Desk Reference to the Diagnostic Criteria from DSM-5 Arlington, Virginia: Author.
American Psychological Association. (2020). Publication manual of the American Psychological Association (7th ed.). Washington, DC: Author.
Corey, G. (2015). Theory and Practice of Counseling and Psychotherapy (10th ed.). Brooks/Cole Publishing Company: Belmont, CA.
Clinical Medical Report Rubric
Criteria
Ratings
Pts
Chief Complaint – Patient’s presenting complaint
view longer description
2 pts
Chief Complaints identifies reason for the visit
1 pts
Chief Complaint does not identify reason for the visit
0 pts
No Chief Complaint
2 / 2 pts
History of Present Illness – Symptom analysis for each complaint. Assessment elements to be documented will include: Associated symptoms, onset, duration, quality, severity, presence or absence of stressors, factors that alleviate or exacerbate symptoms, functional ability
view longer description
4 pts
Full symptoms assessment for each complaint
4 points
3 pts
Majority of symptom analysis is evident for each complaint
3 points
2 pts
Partial symptom analysis for each complaint
2-1
0 pts
No symptom assessment
0 points
2 / 4 pts
Psychiatric Review of Symptoms (Psych ROS) – Asks about symptoms for Depression, Mania, GAD, Panic, OCD, Trauma, Social anxiety, phobias, Hallucinations, Delusions, ADHD, disordered eating
view longer description
4 pts
Completes a full Psych ROS
4 points
3 pts
Addresses most of Psych ROS (has 7 or more components)
3 points
2 pts
Addresses partial Psych ROS (has less than 7 components)
2-1 points
0 pts
No Psych ROS
0 points
4 / 4 pts
Safety Assessment – Includes suicidal ideation/homicidal, access to weapons, past suicidal/homicidal attempts, other risk factors
view longer description
3 pts
Detailed safety assessment
3 points
2 pts
Partial Safety Assessment
2 points
1 pts
Safety Assessment needs improvement
1 point
0 pts
No safety assessment
0 Points
3 / 3 pts
Substance Abuse history – Includes detail of each substance used, last used and past interventions (rehab, groups)
view longer description
3 pts
Detailed substance abuse history
2 points
2 pts
Substance Abuse history mostly complete
2 points
1 pts
Substance Abuse history need improvement
1 point
0 pts
No substance abuse history
0 Points
2 / 3 pts
Past Psychiatric History – Includes past therapy, psychiatry, hospitalizations, past psychiatric medications
view longer description
3 pts
Detailed Past Psychiatric History
3 points
2 pts
Past Psychiatric History mostly complete
2 points
1 pts
Past Psychiatric History needs improvement
1 Point
0 pts
No Past Psychiatric History
0 Points
3 / 3 pts
Past Medical History – Includes last PE, current medical conditions, hx of surgeries, current non-psychiatric medications
view longer description
3 pts
Has detailed Past Medical History
3 Points
2 pts
Past Medical History is mostly complete
2 points
1.2 pts
Past Medical History needs improvement
1 point
0 pts
No Past Medical History
0 Points
3 / 3 pts
Medical Review of Systems – Includes Constitution, EENT, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal, Integumentary, Endocrine, Neurological, Immunological, Reproductive, and Hematological Systems
view longer description
3 pts
Has >90% of Medical Review of Systems accurately documented
3 points
2 pts
Has 50% of Medical ROS accurately documented
2 Points
1 pts
Has less than 50% of Medical ROS or system documentation is very limited
1 Point
0 pts
No Family History
0 Points
2 / 3 pts
Family History – Includes family psychiatric and pertinent medical history, family substance abuse, family legal history, family SI/HI history
view longer description
3 pts
Has complete Family history
3 points
2 pts
Family history mostly complete
2 points
1 pts
Family History needs improvement
1 point
0 pts
No Family History
0 Points
3 / 3 pts
Developmental History – Includes childhood development, childhood home atmosphere, educational history, employment history
view longer description
3 pts
Has complete Developmental History
3 Points
2 pts
Developmental History is mostly complete
2 Points
1 pts
Developmental History needs improvement
1 Point
0 pts
No Developmental History
0 Points
2 / 3 pts
Social History – Includes relationship (SO, Family), current supports, spirituality, hobbies, future plans
view longer description
3 pts
Has full Social History
3 Points
2 pts
Has most of Social History
2 points
1 pts
Social History needs improvement
1 Point
0 pts
No Social History
0 points
3 / 3 pts
PE & Objective Information Includes VS, Wt/Ht, BMI, Labs and any other pertinent information (i.e. screenings if present) If labs are not available, documents what labs they would like to see for this patient
view longer description
2 pts
Full PE and labs documented
2 points
1 pts
Partial PE
1 Points
0 pts
No PE or Labs
0 Points
2 / 2 pts
Mental Status Examination (MSE) – Includes Appearance, Behavior, Attitude, Speech, Affect, Mood, Thought Process & Content, Attention, Memory, Orientation, Memory, Abstraction, Intelligence, Insight, Judgment
view longer description
8 pts
Complete components of MSE accurately
8 Points
6 pts
Documents the majority of MSE components accurately
7-6 Points
4 pts
Documents half the components of MSE accurately
5-4 Points
2 pts
Documents less than half MSE components accurately
2-1 Points
0 pts
No MSE
0 Points
8 / 8 pts
Diagnostic Formulation – The diagnosis(es) flow from the histories and exam. Each diagnosis has rationale and supporting evidence taken from the histories/Exam
view longer description
18 pts
>90% diagnosis(es) are addressed in a clear and organized manner, including rationale for each Dx that is supported by the histories/exam
18 Points
11 pts
Majority of diagnosis(es) are addressed in a clear and organized manner, limited rationale or supporting evidence for each Dx
17-11 Point
6 pts
Diagnosis(es) addressed but lacking organization and wordy, no rationale for each Dx
10-6 Points
1 pts
Diagnosis(es) identified in brief manner; No rationale for each Dx OR inaccurate Dx
5-1 Points
0 pts
No Diagnostic Formunlation
0 Points
Comments
see comments in the paper. You need to pull patient history into the diagnostic discussion
16 / 18 pts
Differential Diagnosis(es) – Includes possible diagnosis(es) identified in histories but missing criteria to rule in completely, gives rationale for each DDx
view longer description
10 pts
All Differential Diagnosis(es) identified from the history and rationale is documented in a clear and concise manner
10 Points
5 pts
Partial Differential Diagnosis(es) identified from the histories and rationale documented in a clear and concise manner
9-5 Points
1 pts
Has limited rationale documented for identified DDx
4-1 Points
0 pts
No DDx identified
0 Points
10 / 10 pts
Problem List – Includes the ICD-10 and DSM diagnostic codes for all Dx, DDx and medical dx identified
view longer description
2 pts
All codes are listed for identified Dx & DDx
2 Points
1 pts
Missing ICD-10 and DSM codes
1 Point
0 pts
No Codes Listed
0 points
2 / 2 pts
Treatment Planning: Pharmacological – Identifies appropriate medication(s) for identified Diagnosis(es); Written as a script, including medication name, dose, sig, refills
view longer description
4 pts
Has appropriate use of pharmacological intervention written in the form of script
4 Points
2 pts
Has medication identified but missing dose and sig OR Potential dangerous interactions with other medications
Points 3-2
1 pts
Incorrect use or incorrect dose of medication(s) OR possible contraindications
1 Point
0 pts
No medications identified
0 Points
2 / 4 pts
Treatment Planning: Non-pharmacological – Includes referrals, therapies, other interventions (i.e. exercise, support groups)
view longer description
4 pts
Identifies comprehensive list of non-pharmacological interventions for pt need
4 Points
1 pts
Identified Partial list of non-pharmacological interventions for pt need
3-1 Points
0 pts
No Non-pharmacological Interventions identified
0 Points
4 / 4 pts
Treatment Planning: Education – Includes disease prognosis, medication education (side effects, administration, off label use), safety planning, nutrition, sleep hygiene, how to reach provider….
view longer description
4 pts
Addresses all educational needs
4 Points
2 pts
Addresses the majority of educational needs
3-2 Points
1 pts
Educational needs addressed but needs improvement
1 Point
0 pts
No educational needs addressed
0 Points
4 / 4 pts
Psychopharmacology Rationale (Psychiatric Meds Only) – Thorough explanation that includes medication class, mechanism of action, side effects, black box warnings, contraindications. Also includes rationale as to why each medication was chosen for this patient. Uses high quality evidence based resources to support medication choices
view longer description
5 pts
Includes all elements listed and full rationale for medication(s) chosen
5 Points
4 pts
Includes most elements addressed and rationale for medication(s) chosen
4 Points
3 pts
For each medication chosen has several missing elements and/or brief to no rationale
3-1 Points
0 pts
No psychopharmacology rationale provided
0 Points
4 / 5 pts
Reflection and Supervision Log – Reflection includes what you have learned from clinical encounter, questions regarding clinical issues, thoughts on challenges, problems, successes, and your progress toward Class Objectives Supervision includes the number of hours of supervision obtained since your last clinical medical report and a summary of what was discussed with your preceptor
view longer description
3 pts
Includes both Weekly Reflection that includes progress toward clinical objectives and Supervision Log
3 Points
2 pts
Includes weekly reflection and Supervision logs, does not address progress toward clinical objectives
2 Points
1.8 pts
Missing either Weekly Reflection or Clinical Supervision Log
1 Point
0 pts
No Weekly Reflection or Clinical Supervision Log
0 Points
3 / 3 pts
Overall Note – Note is organized, succinct, clear understanding of subjective and objective data. Grammar and punctuation are correct. If references used, APA format is correct
view longer description
6 pts
Note is organized, succinct, clear understanding of subjective and objective data. Grammar and punctuation are correct
6 Points
3 pts
Note is somewhat organized, succinct, clear understanding of subjective and objective data. And/or mistakes in grammar and punctuation, if references used has mistakes in APA format
5-1
0 pts
Poor organization of note, use of grammar/puncuation
0 Points
6 / 6pts
90/100
Comprehensive Psychiatric Evaluation #1 instructor feedback:
You have done a great job in this medical report. Numerous comments in the medical report for you to synthesize. Resist the urge to include conclusions and judgments at the end of every area of assessment as they are not needed and detract from the flow of this clinical document. Allow your reader to draw their own conclusions instead as you lead them down the path to your diagnosis. Well done! Let me know if you have any questions
Note: some things have to be reorganized to the proper section and some sentences/info/concluding statements can be omitted in future medical reports.
Unformatted Attachment Preview
RE: Comprehensive Psychiatric Evaluation #3, Objective Report
In this assignment we are given door information #3 to write a comprehensive psychiatric
evaluation objective medical report. In this hypothetical, the hypothetical door information
is all we would get right before entering the clinical room and seeing the patient, everything
else would have to be obtained from the patient and properly cited using patient quotes or
appropriate references, for example. For the comprehensive psychiatric evaluation #3, we
can make up our own hypothetical door information that aligns with our ideal
patient/clinical scenario. Do not use anxiety as the patient´s psychiatric disorder as I have
already used anxiety in the past per the attached sample. We can make up the patient´s
chief complaint to be characteristic of ADHD and other psychiatric mental health condition
with the appropriate evidence throughout, of course. For information not provided in the
door information, we can make it up to come up with our ideal clinical scenario/patient.
However, information documented should align with the door information and be
supported by evidence such as patient detailed info provided during a detailed and
comprehensive clinical evaluation and interview that asks a series of several detailed
questions such as onset of condition, stress factors, trouble sleeping, etc
In the future, following the same instructions and using faculty feedback, we will work on
future medical reports.
I already completed clinical medical report #1 and received faculty feedback in PDF
format, 90/100, with instructor feedback in the PDF document titled medical report #1
instructor feedback along with the rubric filled out below and attached as a separate
document.
The medical info such as medications to prescribe should not be difficult to find using
google and appropriate references. However, faculty as you will see from their feedback
want detailed responses such as severity of onset, how long ago did it start, evidence from
the patient´s own words that we can make up, etc.
If you need any additional info, feel free to ask along the way.
From previous instructor feedback, some comments are very helpful moving forward
including writing the chief complaint as a quote in the patient´s words, etc.
As you will see, in my Comprehensive Psychiatric Evaluation #1 instructor feedback PDF,
faculty want more detail narratives in some areas such as severity of onset, how long ago
did it start, evidence from the patient´s own words that we can make up, what questions we
would ask such as whether the patient has access to weapons at home?, and in other areas,
more bulleted lists. Further, we can omit concluding statements while some details also
have to be included in the History of Present IIllness, HPI section, for example.
Kindly use the rubric to include ALL SUPTOPICS AND DETAILS REQUESTED
following the sample religiously. The sample medical report #1 attached as a word
document should be of great help. Kindly use medical report #1 as a model for medical
report #3.
According to the door information, we need to prescribe at least two medications and
provide the psychopharmacology rationale for one scheduled and one prn medication.
Door information instructions regarding the two medications prescribed:
Psychopharmacology rationale should include: A thorough explanation of all psychiatric
medications prescribed or continued. This is including but not limited to the mechanism of
action, the medication class, potential side effects, potential medication interactions if
taking other medications, black box warnings, contraindications, and any prescribing
considerations for these prescribed medications. Then provide a rationale on why you
chose these specific medications for this patient.
Google may assist in determining which medications to prescribe to ADHD patients, for
example, including dose mg, etc.
I am attaching clinical medical report #1 with instructor feedback included example titled:
Comprehensive Psychiatric Evaluation #1 earned 90 with instructor feedback
References should be used extensively and cited throughout the medical report with in-text
citations in APA 7th Ed. I have provided references from the syllabus below and you can
use these or other references no older than 5 years old, look at the examples for the types of
references used). Stahl (2021) is highly recommended for prescriptions and American
Psychiatric Association (2022) is highly recommended for diagnoses and criteria. You may
access many of the references at libgen.is as needed or I can provide them to you upon
request, but the problem is that the file sizes are large.
References
American Psychiatric Association (2022). Diagnostic and Statistical Manual of Mental
Disorders DSM 5-TR (5th ed. Text Revision). American Psychiatric Association:
Arlington, Virginia. ISBN-10: 0890425760
Carlat, D. (2017). The Psychiatric Interview (4th Ed.). Lippincott Williams & Wilkins:
Philadelphia, ISBN-13: 978-1496327710 ISBN-10: 9781496327710
Stahl, S.M. (2021). Stahl’s Essential Psychopharmacology Prescriber’s Guide (7th
Ed.). Cambridge University Press: New York, NY. ISBN-13: 978-1108926010 ISBN10: 1108926010
Zimmerman, M. (2013). Interview Guide for Evaluating DSM-5 Psychiatric Disorders and
the Mental Status Examination. Psych Products Press: East Greenwich, RI. ISBN-13: 9780963382115 ISBN-10: 096338211X
American Psychiatric Association (2022). Desk Reference to the Diagnostic Criteria from
DSM- 5TR. Arlington, Virginia: APA ISBN-10 : 089042580 ISBN-13 : 9780890425800
Boland, R., Verduin, M.L & Ruiz, P. (2022). Kaplan and Sadock’s Synopsis of Psychiatry:
Behavioral Sciences/Clinical Psychiatry (12th Ed,). Lippincott Williams & Wilkins:
Philadelphia, PA. ISBN-13: 978-1975145569; ISBN-10: 1975145569
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental
Disorders DSM 5 (5th ed.).America Psychiatric Association: Arlington, Virginia
Boland, R., Verduin, M.L & Ruiz, P. (2022). Kaplan and Sadock’s Synopsis of Psychiatry:
Behavioral Sciences/Clinical Psychiatry (12th Ed,). Lippincott Williams & Wilkins:
Philadelphia, PA. ISBN-13: 978-1975145569; ISBN-10: 1975145569
Carlat, D. (2016). The Psychiatric Interview (4th Ed.). Lippincott Williams & Wilkins:
Philadelphia, PA. ISBN-13: 978-1496327710 ISBN-10: 9781496327710
Wheeler K. (2022). Psychotherapy for the Advanced Practice Psychiatric Nurse: A
How-To Guide for Evidence-Based Practice. 3rd Edition. Springer Publishing; New
York, ISBN-13: 978-0826193797 ISBN-10: 082619379X
American Psychiatric Association (2013). Desk Reference to the Diagnostic Criteria from
DSM-5 Arlington, Virginia: Author.
American Psychological Association. (2020). Publication manual of the American
Psychological Association (7th ed.). Washington, DC: Author.
Corey, G. (2015). Theory and Practice of Counseling and Psychotherapy (10th ed.).
Brooks/Cole Publishing Company: Belmont, CA.
Clinical Medical Report Rubric
Criteria
Ratings
Pts
Chief Complaint – Patient’s presenting complaint
view longer description
2 pts
Chief Complaints
identifies reason for
the visit
1 pts
Chief Complaint
does not identify
reason for the visit
0 pts
No Chief Complaint
2/2
pts
History of Present Illness – Symptom analysis for
each complaint. Assessment elements to be
documented will include: Associated symptoms,
onset, duration, quality, severity, presence or absence
of stressors, factors that alleviate or exacerbate
symptoms, functional ability
view longer description
4 pts
Full symptoms
assessment for each
complaint
4 points
3 pts
Majority of symptom
analysis is evident
for each complaint
3 points
2 pts
Partial symptom
analysis for each
complaint
2-1
0 pts
No symptom
assessment
0 points
2/4
pts
Psychiatric Review of Symptoms (Psych ROS) – Asks
about symptoms for Depression, Mania, GAD, Panic,
OCD, Trauma, Social anxiety, phobias,
Hallucinations, Delusions, ADHD, disordered eating
view longer description
4 pts
Completes a full
Psych ROS
4 points
3 pts
Addresses most of
Psych ROS (has 7 or
more components)
3 points
2 pts
Addresses partial
Psych ROS (has less
than 7 components)
2-1 points
0 pts
No Psych ROS
0 points
4/4
pts
Safety Assessment – Includes suicidal
ideation/homicidal, access to weapons, past
suicidal/homicidal attempts, other risk factors
view longer description
3 pts
Detailed safety
assessment
3 points
2 pts
Partial Safety
Assessment
3/3
pts
2 points
1 pts
Safety Assessment
needs improvement
1 point
0 pts
No safety assessment
0 Points
Substance Abuse history – Includes detail of each
substance used, last used and past interventions
(rehab, groups)
view longer description
3 pts
Detailed substance
abuse history
2 points
2 pts
Substance Abuse
history mostly
complete
2 points
1 pts
Substance Abuse
history need
improvement
1 point
0 pts
No substance abuse
history
0 Points
2/3
pts
Past Psychiatric History – Includes past therapy,
psychiatry, hospitalizations, past psychiatric
medications
view longer description
3 pts
Detailed Past
Psychiatric History
3 points
2 pts
Past Psychiatric
History mostly
complete
2 points
1 pts
Past Psychiatric
History needs
improvement
1 Point
0 pts
No Past Psychiatric
History
3/3
pts
0 Points
Past Medical History – Includes last PE, current
medical conditions, hx of surgeries, current nonpsychiatric medications
view longer description
3 pts
Has detailed Past
Medical History
3 Points
2 pts
Past Medical History
is mostly complete
2 points
1.2 pts
Past Medical History
needs improvement
1 point
0 pts
No Past Medical
History
0 Points
3/3
pts
Medical Review of Systems – Includes Constitution,
EENT, Cardiovascular, Respiratory, Gastrointestinal,
Genitourinary, Musculoskeletal, Integumentary,
Endocrine, Neurological, Immunological,
Reproductive, and Hematological Systems
view longer description
3 pts
Has >90% of
Medical Review of
Systems accurately
documented
3 points
2 pts
Has 50% of Medical
ROS accurately
documented
2 Points
1 pts
Has less than 50% of
Medical ROS or
system
documentation is
very limited
1 Point
0 pts
No Family History
0 Points
2/3
pts
Family History – Includes family psychiatric and
pertinent medical history, family substance abuse,
family legal history, family SI/HI history
view longer description
3 pts
Has complete Family
history
3 points
3/3
pts
2 pts
Family history
mostly complete
2 points
1 pts
Family History needs
improvement
1 point
0 pts
No Family History
0 Points
Developmental History – Includes childhood
development, childhood home atmosphere,
educational history, employment history
view longer description
3 pts
Has complete
Developmental
History
3 Points
2 pts
Developmental
History is mostly
complete
2 Points
1 pts
Developmental
History needs
improvement
1 Point
0 pts
No Developmental
History
0 Points
2/3
pts
Social History – Includes relationship (SO, Family),
current supports, spirituality, hobbies, future plans
view longer description
3 pts
Has full Social
History
3 Points
2 pts
Has most of Social
History
2 points
1 pts
Social History needs
improvement
1 Point
0 pts
3/3
pts
No Social History
0 points
PE & Objective Information Includes VS, Wt/Ht,
BMI, Labs and any other pertinent information (i.e.
screenings if present) If labs are not available,
documents what labs they would like to see for this
patient
view longer description
2 pts
Full PE and labs
documented
2 points
1 pts
Partial PE
1 Points
0 pts
No PE or Labs
0 Points
2/2
pts
Mental Status Examination (MSE) – Includes
Appearance, Behavior, Attitude, Speech, Affect,
Mood, Thought Process & Content, Attention,
Memory, Orientation, Memory, Abstraction,
Intelligence, Insight, Judgment
view longer description
8 pts
Complete
components of MSE
accurately
8 Points
6 pts
Documents the
majority of MSE
components
accurately
7-6 Points
4 pts
Documents half the
components of MSE
accurately
5-4 Points
2 pts
Documents less than
half MSE
components
accurately
2-1 Points
0 pts
No MSE
0 Points
8/8
pts
Diagnostic Formulation – The diagnosis(es) flow from
the histories and exam. Each diagnosis has rationale
and supporting evidence taken from the
histories/Exam
view longer description
18 pts
>90% diagnosis(es)
are addressed in a
clear and organized
manner, including
16 /
18
pts
rationale for each Dx
that is supported by
the histories/exam
18 Points
11 pts
Majority of
diagnosis(es) are
addressed in a clear
and organized
manner, limited
rationale or
supporting evidence
for each Dx
17-11 Point
6 pts
Diagnosis(es)
addressed but
lacking organization
and wordy, no
rationale for each Dx
10-6 Points
1 pts
Diagnosis(es)
identified in brief
manner; No
rationale for each Dx
OR inaccurate Dx
5-1 Points
0 pts
No Diagnostic
Formunlation
0 Points
Comments
see comments in the
paper. You need to
pull patient history
into the diagnostic
discussion
Differential Diagnosis(es) – Includes possible
diagnosis(es) identified in histories but missing
criteria to rule in completely, gives rationale for each
DDx
view longer description
10 pts
All Differential
Diagnosis(es)
identified from the
history and rationale
is documented in a
10 /
10
pts
clear and concise
manner
10 Points
5 pts
Partial Differential
Diagnosis(es)
identified from the
histories and
rationale
documented in a
clear and concise
manner
9-5 Points
1 pts
Has limited rationale
documented for
identified DDx
4-1 Points
0 pts
No DDx identified
0 Points
Problem List – Includes the ICD-10 and DSM
diagnostic codes for all Dx, DDx and medical dx
identified
view longer description
2 pts
All codes are listed
for identified Dx &
DDx
2 Points
1 pts
Missing ICD-10 and
DSM codes
1 Point
0 pts
No Codes Listed
0 points
2/2
pts
Treatment Planning: Pharmacological – Identifies
appropriate medication(s) for identified
Diagnosis(es); Written as a script, including
medication name, dose, sig, refills
view longer description
4 pts
Has appropriate use
of pharmacological
intervention written
in the form of script
4 Points
2 pts
Has medication
identified but
missing dose and sig
2/4
pts
OR Potential
dangerous
interactions with
other medications
Points 3-2
1 pts
Incorrect use or
incorrect dose of
medication(s) OR
possible
contraindications
1 Point
0 pts
No medications
identified
0 Points
Treatment Planning: Non-pharmacological – Includes
referrals, therapies, other interventions (i.e. exercise,
support groups)
view longer description
4 pts
Identifies
comprehensive list of
non-pharmacological
interventions for pt
need
4 Points
1 pts
Identified Partial list
of nonpharmacological
interventions for pt
need
3-1 Points
0 pts
No Nonpharmacological
Interventions
identified
0 Points
4/4
pts
Treatment Planning: Education – Includes disease
prognosis, medication education (side effects,
administration, off label use), safety planning,
nutrition, sleep hygiene, how to reach provider….
view longer description
4 pts
Addresses all
educational needs
4 Points
2 pts
Addresses the
majority of
4/4
pts
educational needs
3-2 Points
1 pts
Educational needs
addressed but needs
improvement
1 Point
0 pts
No educational needs
addressed
0 Points
Psychopharmacology Rationale (Psychiatric Meds
Only) – Thorough explanation that includes
medication class, mechanism of action, side effects,
black box warnings, contraindications. Also includes
rationale as to why each medication was chosen for
this patient. Uses high quality evidence based
resources to support medication choices
view longer description
5 pts
Includes all elements
listed and full
rationale for
medication(s) chosen
5 Points
4 pts
Includes most
elements addressed
and rationale for
medication(s) chosen
4 Points
3 pts
For each medication
chosen has several
missing elements
and/or brief to no
rationale
3-1 Points
0 pts
No
psychopharmacology
rationale provided
0 Points
4/5
pts
Reflection and Supervision Log – Reflection includes
what you have learned from clinical encounter,
questions regarding clinical issues, thoughts on
challenges, problems, successes, and your progress
toward Class Objectives Supervision includes the
number of hours of supervision obtained since your
last clinical medical report and a summary of what
was discussed with your preceptor
3 pts
Includes both
Weekly Reflection
that includes
progress toward
clinical objectives
and Supervision Log
3 Points
3/3
pts
view longer description
Overall Note – Note is organized, succinct, clear
understanding of subjective and objective data.
Grammar and punctuation are correct. If references
used, APA format is correct
view longer description
2 pts
Includes weekly
reflection and
Supervision logs,
does not address
progress toward
clinical objectives
2 Points
1.8 pts
Missing either
Weekly Reflection or
Clinical Supervision
Log
1 Point
0 pts
No Weekly
Reflection or Clinical
Supervision Log
0 Points
6 pts
Note is organized,
succinct, clear
understanding of
subjective and
objective data.
Grammar and
punctuation are
correct
6 Points
3 pts
Note is somewhat
organized, succinct,
clear understanding
of subjective and
objective data.
And/or mistakes in
grammar and
punctuation, if
references used has
mistakes in APA
format
5-1
0 pts
Poor organization of
6 / 6pts
note, use of
grammar/puncuation
0 Points
90/100
Comprehensive Psychiatric Evaluation #1 instructor feedback:
You have done a great job in this medical report. Numerous comments in the medical
report for you to synthesize. Resist the urge to include conclusions and judgments at the
end of every area of assessment as they are not needed and detract from the flow of this
clinical document. Allow your reader to draw their own conclusions instead as you lead
them down the path to your diagnosis. Well done! Let me know if you have any questions
Note: some things have to be reorganized to the proper section and some
sentences/info/concluding statements can be omitted in future medical reports.
Door Information #3
Patient Name: MS
Age: 66 Y.O. Caucasian Female
Physical Exam:
BP:129/75
HR: 87
RR: 20
Height:5’ 5”
Weight:190 lbs
BMI: 31.62
Allergies: Drug, food, or environmental allergies?
Screenings:
GAD-7 = 5/21
PHQ-9 =6/27
MDQ = 3/13 Question No
Adult ADHD Self-Report Scale (ASRSv1.1) = 14
Diagnoses:
ADHD/Attention-Deficit hyperactivity disorder
Differential Diagnoses
1.Oppositional defiant disorder pg 73Diagnostic and Statistical Manual Of Mental Disorders 5th
Ed. Text Revision/DSM-5-T
2.Disruptive mood dysregulation disorderpg 74 DSM
3.PTSD/Post Traumatic Stress Disorderpg 74 DSM
4.Anxiety disorders pg 74 DSM
5.Specific Learning Disorderspg73
6. Depressive Disorders Pg 74 DSM
7. Bipolar disorder PGPG 74 DSM
Medications:
Previous medication trials? No
Choose 2 medications that you would prescribe for this client. One should be a scheduled
medication, the other a prn mediation.
Medication #1, Scheduled
Medication #2, Prescription, PRN
ADHD
Medication #1, Scheduled
*ADDERALL EXTENDED RELEASE 10 MG/DAY IN THE MORNING, MAY INCREASE
BY 5-10MG/DAY AT WEEKLY INTERVALS, MAX DOSE 30 MG/DAY. PG 47 STAHL’S
PSYCHOPHARMACOLOGY 7TH ED.
*STRATTRA 40 MG PO QD – AFTER 7 DAYS MAY INCREASE TO 1.2MG/KG/DAY CAN MAX DOSE 1.4MG/KG PER DAY OR 100 MG/KG/DAY,WHICHEVER IS LESS. PG
80 STAHL’S PSYCHOPHARMACOLOGY 7TH ED.
PRN DOSING IS DONE USING IMMEDIATE-RELEASE STIMULANTS SUCH AS
ADDERALL, OR DEXEDRINE
NON-PHARMACOLOGICAL ADHD
One widely used approach to ADHD is cognitive behavioral therapy (CBT). This type of
psychotherapy helps people change negative thought patterns into positive, healthier ways of
thinking. The idea is that if you change the way you think about a situation, your feelings and
behaviors can change, too
1
Practicum Clinical Journal #1
Date: October 5, 2023
Time started: 10:00 a.m.-11:30 a.m.
Site: Integrated Healthcare Services Behavioral Health/IHS BH
Level of Supervision: Primary (>50%)
Identifying Data
Patient Initials: AD
Age: 35 years
Gender: Female
Marital Status: Married
Religion: Unknown
Occupation: Office Manager
Language Spoken: English
Living Arrangements: Lives with spouse and two children in a condominium
Source and Reliability
Accompanied By: None; patient presented alone
Source of Information: Patient
Chief Complaint (CC):”Constant worrying and fear that something terrible is going to happen.”
History of Present Illness
AD states that for the past six months, she has been experiencing excessive worrying,
restlessness, and a constant sense of unease. She reports that these symptoms have been
progressively getting worse and have become increasingly intrusive, significantly affecting her
daily life and causing sleep disturbances. According to AD, the quality of her anxiety feels like
2
an overwhelming sense of dread, and she describes it as a constant ‘knot in her stomach.’ She
rates the severity of her symptoms as 9 out of 10, emphasizing the profound impact on her
overall well-being. AD mentions that these symptoms have been persistent for the past six
months, indicating their chronic nature. She further reports that her anxiety seems unpredictable,
lacking any specific timing or context-dependent trigger, and it occurs even when there are no
apparent stressors. AD states that while she briefly finds relief through mindfulness exercises,
her anxiety quickly returns, and there are no consistent modifying factors that alleviate her
distress. Additionally, she reports experiencing associated physical manifestations, including
muscle tension, headaches, and gastrointestinal discomfort, which further contribute to her
distress.
Psychiatric Review of Symptoms (Psych ROS)
Depression: AD reports no feelings of depression, stating that she generally does not experience
prolonged periods of sadness or hopelessness. However, she states that she feels tired, has
trouble sleeping, and sometimes has low interest in doing things. Her PHQ score was 9.
Mania: AD states that she has not experienced any symptoms of mania, such as elevated mood,
excessive energy, or impulsivity. AD states that she is not easily irritable and denies any negative
thoughts. Her MDQ score was 4.
GAD (Generalized Anxiety Disorder): AD emphasizes that her primary concern leading to the
visit is her overwhelming and persistent anxiety, which she describes as a constant state of worry
and unease. She also adds that she is easily fatigued, irritable, difficulty in concentrating and
sleeps about 4 hours then wakes up continuously. The GAD-7 score for AD is 14, which is
moderate anxiety.
3
Panic: AD reports occasional panic attacks, describing them as sudden and intense episodes of
extreme fear, palpitations, and shortness of breath. She mentions that these episodes can be
distressing and disruptive.
OCD (Obsessive-Compulsive Disorder): AD states that she has not been troubled by
obsessions or compelled to perform repetitive behaviors characteristic of OCD.
Trauma: AD firmly denies a history of trauma, indicating that she has not experienced any
significant traumatic events in her life.
Social Anxiety: AD does not mention specific social anxiety symptoms, suggesting that her
anxiety is not limited to social situations but is more generalized.
Phobias: AD does not identify any specific phobias or intense fears that trigger her anxiety.
Hallucinations: AD states that she has not experienced any hallucinations, indicating that she
does not perceive things that are not present.
Delusions: AD reports no delusions, affirming that she maintains a firm grip on reality.
ADHD (Attention-Deficit/Hyperactivity Disorder): AD mentions that she has not noticed
symptoms associated with ADHD, such as inattention, hyperactivity, or impulsivity.
Disordered Eating: AD states that she does not engage in any disordered eating behaviors, such
as binge eating, purging, or restrictive eating patterns.
Safety Assessment
Suicidal Ideation/Homicidal: AD firmly denies experiencing any current or past thoughts of
harming herself or others. She emphasizes that she has never entertained the idea of suicide or
homicidal actions throughout her life.
4
Access to Weapons: AD states that there is no access to any weapons within her household. She
clarifies that her living environment is free from any firearms, sharp objects, or potentially
harmful items.
Past Suicidal/Homicidal Attempts: AD states that she has never made any suicidal or
homicidal attempts in the past. She reports that her history is void of any such actions,
reinforcing her commitment to her own safety and the safety of others.
Other Risk Factors: AD indicates that there are no other immediate risk factors of concern. She
does not mention any circumstances, relationships, or situations that could pose a risk to her
mental or emotional well-being.
Substance Abuse History
Alcohol: AD reports her alcohol consumption habits, describing occasional use typically limited
to social occasions. She clarifies that her alcohol intake is moderate and does not result in
excessive or problematic drinking.
Tobacco: AD denies any use of tobacco products, highlighting her non-smoker status.
Illicit Drugs: AD states that she has never engaged in the use of illicit drugs. She emphasizes her
commitment to a drug-free lifestyle.
Prescription Medications: AD indicates that she is currently taking oral contraceptives solely
for birth control purposes. She emphasizes that this medication is prescribed and used in
accordance with medical guidelines.
Past Psychiatric History: AD asserts that she has no prior history of psychiatric treatment or
medications. She states that her visit marks her first engagement with psychiatric evaluation and
intervention, implying that her current symptoms of anxiety are her first encounter with such
mental health concerns.
5
Past Medical History
Insurance and Providers: AD is currently insured through XYZ Insurance. She states that she
had her comprehensive body check-up three years ago.
Medical History: AD reports that her primary care provider is Dr. Smith, and her psychiatrist is
Dr. Johnson. She states that she is currently under no medication. She indicated that yesterday
she took 400mg ibuprofen for her headache. She states that she took the medication once and the
headache subsided.
Seizure History:AD reports no history of seizures or epilepsy. She has never experienced
seizures, and there is no family history of seizure disorders.
Last Physical Examination: AD affirms that she underwent her most recent physical
examination within the past year, which was part of her routine check-up. This indicates her
commitment to regular health maintenance and suggests an active interest in monitoring her
physical well-being.
Current Medical Conditions:AD clearly states that she is not currently dealing with any
medical conditions. Her self-report is indicative of a generally healthy physical state, devoid of
any ongoing illnesses or health concerns.
OTC/Supplements: 400mg Ibuprofen yesterday for her headache. Denies being on any
supplements.
History of Surgeries: AD provides insight into her surgical history by mentioning that she
underwent an appendectomy at the age of 18. This information helps establish a comprehensive
medical background, highlighting a past surgical procedure that is relevant to her current health
status.
6
Allergies: She states that she does not react to any drug or food. She adds that there are no
known environmental allergies.
Current Non-Psychiatric Medications: AD confirms that she is currently taking oral
contraceptives, specifically a combination of ethinyl estradiol and norgestimate, on a daily basis.
This medication, typically prescribed for birth control, is mentioned explicitly, demonstrating her
awareness of and adherence to prescribed non-psychiatric medications.
Medical Review of Systems
Constitutional: AD reports the absence of fever, weight loss, or fatigue. These observations are
essential in ruling out systemic illnesses that might present with these constitutional symptoms.
Her report suggests an overall sense of well-being in terms of general health.
HEENT (Head, Eyes, Ears, Nose, Throat):AD reports that there are no visual or auditory
disturbances reported by AD. This indicates normal sensory functions in her eyes and ears,
which is vital for her daily functioning and quality of life.
Cardiovascular: AD states that she has not experienced chest pain or palpitations. These
symptoms can be indicative of cardiac issues, and their absence in her report is reassuring
regarding her heart health.
Respiratory: She denies shortness of breath or cough. These symptoms are essential indicators
of respiratory conditions. The absence of such symptoms suggests that AD’s respiratory system
is functioning normally.
Gastrointestinal: AD mentions occasional abdominal discomfort attributed to anxiety. This
observation is significant, as it aligns with her anxiety disorder diagnosis. Anxiety can manifest
with gastrointestinal symptoms, and her disclosure provides context for her condition.
7
Genitourinary: AD does not report any urinary symptoms. This information suggests the
absence of urinary tract problems or related issues.
Musculoskeletal: She acknowledges experiencing muscle tension associated with anxiety. This
symptom is consistent with her generalized anxiety disorder (GAD) diagnosis and is a common
physical manifestation of anxiety.
Integumentary: AD reports no skin issues. This is reassuring, as skin problems can be indicative
of various dermatological conditions, which are not presently a concern for her.
Endocrine: She does not mention any symptoms suggestive of hormonal imbalance. This is
pertinent in ruling out endocrine disorders, which could affect various bodily functions.
Neurologic: AD specifically denies seizures, headaches associated with anxiety, or neurological
deficits. Her clarification regarding headaches underscores their relation to her anxiety and not a
separate neurological issue.
Immunological: She states that she has no history of autoimmune disorders. This information is
significant in assessing her immune system health.
Reproductive: AD notes regular menstrual cycles and no gynecological complaints. This
information indicates normal reproductive and gynecological health.
Hematologic: She reports no bleeding or clotting disorders. Hematological issues, such as
bleeding disorders, can have significant health implications, and her denial of such concerns is
relevant.
Allergies: She denies any history of eczema, asthma, or rhinitis.
Family History
Family Medical History: She states that all her parents are alive and healthy. Indicates that both
her maternal grandparents died due to old age; grandmother at 96 years and grandfather at 99
8
years.. She reports that her paternal grandmother is alive and healthy and her paternal
grandfather died due to a car accident eight years ago. She states that all her siblings are alive
and healthy.
Family Psychiatric History: AD reports that her maternal aunt has a history of depression and
was prescribed sertraline. This information is significant because it suggests a potential genetic
or familial predisposition to mood disorders, particularly depression. It underscores the
importance of considering family psychiatric history when evaluating AD’s mental health, as
genetic factors can play a role in the development of anxiety disorders and depression.
Family Substance Abuse: AD states that there is no significant family history of substance
abuse. This information is relevant in assessing her risk factors for substance use disorders,
which can sometimes co-occur with anxiety disorders.
Family History of Suicides: AD reports no family history of suicides. This is crucial
information, as a family history of suicide can be a risk factor for suicidal ideation or attempts in
individuals. In AD’s case, the absence of such a history is reassuring in terms of suicide risk
assessment.
Family Legal History: There is no relevant legal history in AD’s family. This information helps
provide a more comprehensive understanding of her family background, as legal issues or
involvement with the legal system can impact a person’s mental health and stress levels.
Family SI/HI History: AD states that there is no family history of suicidal ideation or homicidal
ideation. This information is important for assessing the presence of suicidal or homicidal
ideation in her family, as these factors can sometimes be hereditary or indicative of broader
family dynamics.
Developmental History
9
Childhood Development: AD reports normal developmental milestones during her childhood.
This information suggests that she did not experience significant developmental challenges or
delays during her early years, which can be relevant when considering the origins of mental
health conditions.
Childhood Home Atmosphere: She describes her childhood home as stable and nurturing. This
insight into her upbringing pro
