Nrnpprac 6645 Comprehensive Psychiatric Evaluation Note Temp

Nrnpprac 6645 Comprehensive Psychiatricevaluation Note Templateinstru

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: · 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: · 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: · 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 (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 G o Ch a MP. G eneral 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. C aregivers are listed if applicable. H ospitalizations: 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? M edication 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) P sychotherapy or P revious 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: · 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? · Legal history: past hx, any current issues? · 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). A ssessment 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. 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. 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 treatment 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 (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.). 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 1-800-_______ . 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 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. © 2021 Walden University Lab Questions Please complete the following questions. It is important that you use complete sentences and present the questions and answers when you submit your work. Submit the work as a file attachment. This means you will complete all work in a word processing document (e.g., Microsoft Word) and attach the file using the Submit Lab Questions activity in your Course Map. Lab Assignment 1 Use the following template to brainstorm ways a company might market the same commodity to different segments of their market. The first row has been done for you as an example. TABLE 1 Market segments exercise Product Kids Cereal Placing toys in the box Sweatshirts Electronics Books Art Supplies Product Teens Cereal Associating it with a celebrity or athlete Sweatshirts Electronics Books Art Supplies Product Parents Cereal Promoting with money-saving coupons Sweatshirts Electronics Books Art Supplies Product Seniors Cereal Advertising health benefits Sweatshirts Electronics Books Art Supplies Lab Assignment 2 Use the following template to brainstorm the types of purchasing concerns that might be associated with each demographic. The first one has been completed for you as an example. TABLE 2 Demographics exercise Demographic Purchasing Concerns Ages 18-24 Price, peer reviews, convenience, immediacy Income Over $100,000 year Christian Mother of three kids Single man College Graduate Ages 65+ Demographic Explanation Ages 18-24 Typically, this age group is either in college or in an entry-level, low-paying position; therefore, price would be a concern because of a lack of discretionary income. At this age, individuals are heavily influenced by their peers, so social proof will be an effective strategy. Young people are known for their need for instant gratification, so convenience and immediacy will be a factor as well. Income Over $100,000 year As you completed the activity, you may have noticed that you were doing a lot of speculation. Marketers do that too, but they also rely on market research to inform their decisions. Lab Assignment 3 See if you can determine different personality profiles for the following commodities using the following template. Try to come up with as many different types of consumers as possible. The first one has been done for you as an example. TABLE 3 Consumer profiles exercise Commodity Personality Profiles Late night movie premiere Teenagers who want to stay out late, people obsessed with a certain actor or film, people willing to pay more to see something first (possibly competitive), thrill-seekers Country music festival SEC college football game Disney on Ice performance Lab Assignment 4 Now, use the following template to align one of the personality profiles you identified for each commodity with marketing techniques that they would likely respond to. Again, the first one has been completed for you to serve as an example. Note: You may wish to look back at previous units for ideas. TABLE 4 Marketing to profiles exercise Personality Profile Effective Marketing Techniques People willing to pay more to see something first (possibly competitive) Product enhancements, advertisements which feature the scarcity of the one-night premiere, social proof

Paper For Above instruction

The comprehensive psychiatric evaluation is a critical component in the diagnostic process for mental health professionals. It provides a structured framework to gather detailed information about a patient’s psychological, medical, social, and behavioral history, facilitating accurate diagnosis and treatment planning. This essay will delineate the key components of the psychiatric evaluation, discuss the importance of each section, explore the process of differential diagnosis, and reflect on ethical considerations and health promotion strategies relevant to psychiatric assessment.

Introduction

The psychiatric evaluation serves as the foundation for understanding a patient’s mental health status. It encompasses subjective data obtained directly from the patient, objective clinical findings, and an overall assessment that integrates multiple sources of information. Proper documentation and thorough analysis are essential for delivering effective care, ensuring accurate coding, and facilitating interdisciplinary communication.

Subjective Data Collection

The subjective component begins with the chief complaint, articulated verbatim by the patient, which provides the primary reason for seeking evaluation. Coupled with a comprehensive history of present illness (HPI), this section captures the onset, duration, severity, and impact of symptoms. For example, a patient presenting with persistent symptoms of depression may describe feelings of hopelessness, decreased energy, and social withdrawal over several months. A detailed HPI helps narrow differential diagnoses by outlining symptom chronology, intensity, and functional impairment.

The past psychiatric history, including previous diagnoses, hospitalizations, suicidal or homicidal behaviors, and medication responses, offers insights into treatment responsiveness and illness trajectory. The psychosocial background—covering familial, social, occupational, and trauma history—further contextualizes mental health concerns. Substance use history and family psychiatric history are crucial for identifying genetic predispositions and environmental contributors.

In addition, the review of systems (ROS) ensures that physical health factors influencing psychiatric symptoms are considered. It encompasses pertinent medical complaints that may mimic or co-occur with psychiatric disorders, such as thyroid dysfunction or neurological issues.

Objective Data and Diagnostic Results

The objective component involves physical examination findings relevant to mental health, such as psychomotor activity, self-care, and neuromotor abnormalities. Diagnostic tests—including laboratory studies, imaging, or psychometric assessments—assist in ruling out medical illnesses that may present with psychiatric symptoms. For example, thyroid hormone levels can exclude endocrine causes of depression, while neuroimaging may identify neurological lesions mistaken for psychiatric pathology.

Assessment and Mental Status Examination

The mental status examination (MSE) is a systematic assessment of the patient's current psychological functioning. Presenting in paragraph form, it covers appearance, attitude, mood, affect, speech, thought process, thought content, perceptions, cognition, insight, and judgment. An example might describe a patient as disheveled, with flat affect, incoherent speech, persecutory delusions, and impaired judgment, indicating severity and possible psychosis.

The assessment synthesizes subjective and objective data, guides differential diagnoses, and informs treatment planning. It also identifies safety issues, such as suicidality or homicidality, which must be prioritized in management.

Differential Diagnosis

Formulating differential diagnoses involves comparing clinical features against DSM-5 criteria. For illustration, a patient presenting with depressed mood, anhedonia, insomnia, and fatigue could meet criteria for Major Depressive Disorder. However, other considerations include dysthymia, bipolar disorder during a depressive episode, or medication-induced depression. Each differential is supported or ruled out with specific symptoms, duration, and presence or absence of features such as euphoria, mania, psychosis, or substance influence.

Justification of the primary diagnosis relies on the weight of supporting evidence and critical analysis of symptom patterns, course, and psychosocial context. Reflective practice involves considering alternative diagnoses and their implications for treatment.

Legal and Ethical Considerations

Psychiatric assessment must incorporate ethical principles, including confidentiality, informed consent, and cultural competence. Beyond these, clinicians should consider legal issues such as capacity assessment, mandatory reporting, and understanding local laws regarding involuntary treatment. Respecting cultural backgrounds influences diagnostic interpretation, ensuring culturally sensitive care.

For example, hallucinations in a patient from a specific cultural group might be culturally sanctioned spiritual experiences rather than psychopathology, underscoring the need for cultural awareness. Ethical practices also involve careful documentation and shared decision-making to empower patients.

Health Promotion and Disease Prevention

Psychiatrists play a vital role in health promotion by addressing lifestyle factors, social determinants, and preventive strategies