NRNP/PRAC 6645 Comprehensive Psychiatric
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.
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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 Go Cha MP.
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.) NRNP/PRAC 6645 Comprehensive Psychiatric
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, retired?
· 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. 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.
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.). NRNP/PRAC 6645 Comprehensive Psychiatric
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.
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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:
· 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:
· Current Medications:
· Allergies:
· Reproductive Hx:
ROS:
· GENERAL:
· HEENT:
· SKIN:
· CARDIOVASCULAR:
· RESPIRATORY:
· GASTROINTESTINAL:
· GENITOURINARY:
· NEUROLOGICAL:
· MUSCULOSKELETAL:
· HEMATOLOGIC:
· LYMPHATICS:
· ENDOCRINOLOGIC:
Physical exam: if applicable
Diagnostic results:
Assessment
Mental Status Examination:
Differential Diagnoses:
Case Formulation and Treatment Plan:
Reflections:
References
© 2021 Walden University Page 1 of 3
Week 2: Comprehensive Psychiatric Evaluation
Tolani Ayeni
College of Nursing-PMHNP, Walden University
NRNP 6645: Psychotherapy with Multiple Modalities
Stephanie Smith
September 10, 2021
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NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation
CC (chief complaint): The patient is in for a family psychotherapy session and evaluation due to, “the chaos that began when her daughter who recently arrived from Iran claimed that she was sexually and physically abused her father”. The patient and daughter have, “constant fighting, screaming, and yelling in the home”. The patient also complains about the separation that she feels from her children as they grow up with individualistic ideologies of their host culture, different from her personal upbringing in Iran. She complains of “depression because she feels hopeless, and she has so much pain, and no one can do anything about my pain”.
HPI: Patti is a 40 year old Iranian female who is present for a family psychotherapy session and evaluation. Patti reports feelings of hopelessness, helplessness, and consistent pain. Patti’s 21 year old daughter Shireen has recently came to the United States two years ago, within the past two weeks, she has brought up claims against her father for sexual and physical abuse. Patti reports crying and grieving for months, then attempting to involve her daughter Shireen in counseling, Shireen however refuses. Patti is disabled from failed surgeries and has constant pain, her disability prevents her from taking care of herself. Patti reports feelings of depression when she is lonely, resulting in a strained relationship with each of her children because of her unrealistic and high expectations of their caregiver role in her life.
Past Psychiatric History:
· General Statement: No psychiatric history.
· Caregivers (if applicable): No present care givers
· Hospitalizations: No prior hospitalizations
· Medication trials: No medication trials
· Psychotherapy or Previous Psychiatric Diagnosis: Actively in therapy
Substance Current Use and History: No history of substance abuse or alcoholism
Family Psychiatric/Substance Use History: No psychiatric family history.
Genogram
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Psychosocial History: Patti was born in Iran and raised by her parents, she had an arranged marriage a 14 years old. She was physically abused by her husband, then later emigrated to the U.S twelve years ago with her four children on a medical visa and eventually separated from her husband. She actively worked as a caregiver but had two failed foot surgeries that has recently left her disabled. She currently lives with her two boys and requires consistent personal care.
Medical History: Surgeries: Two foot failed foot surgeries.
· Current Medications:
· Allergies: No known drug allergies
Reproductive Hx: Gravida 5, Para 5
ROS:
GENERAL: Generalized obesity, reports of fatigue and weakness. HEENT: Eyes: no blurred vision, difficult vision, no eye pain. Throat: No sneezing,
runny nose, or sore throat, no difficulty swallowing. SKIN: Denies rashes, bruises or lesions CARDIOVASCULAR: Denies chest pain, tachycardia, fatigue, edema RESPIRATORY: Denies shortness of breath, tachypnea, cough, sputum GASTROINTESTINAL: Denies abdominal pain GENITOURINARY: Denies polyuria, incontinence, urgency or frequency NEUROLOGICAL: Denies visual or auditory hallucinations MUSCULOSKELETAL: Complains of pain in feet from failed surgeries HEMATOLOGIC: No anemia, bruising, bleeding. ENDOCRINOLOGIC: No polyuria or polydipsia
Physical exam: Height: 5ft 7in, 176lb, T: 37.1, HR: 83, BP: 146/73, R:22
HEENT:
15yo18yo 24yo 23 yo
21yo
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Head is round and normocephalic, no presence of abnormal lesions or bumps. Pupils are 2mm brisk, equal and reactive. Ears are equal in size, no abnormalities. Dentition is adequate, no lesions or dryness in mouth, moist mucous membranes.
Neck: Neck is supple with no tenderness. Pt has a full range of motion with no stiffness. No lymph nodes on palpation
Chest/Lungs: Patients lung sounds are clear and equal bilaterally. No wheezing or rhonchi auscultated
Heart/Peripheral Vascular: Normal S1 and S2, no clicks or murmurs. No tachycardia No edema, +2 pulses in all extremities, < 2 capillary refill.
Abdomen: Abdomen is distended, soft, and nontender. No palpable masses, no visible redness/rash/edema on the abdomen. Bowel sounds present in all four quadrants. No presence of abdominal hernia
Genital/Rectal:.No reports of itching, no presence of rash Musculoskeletal: Patient has two failed foot surgeries. +Pain, +Tenderness Neurological: There is full sensation in all extremities, +Pain in BLE Skin: No apparent rashes. No jaundice. No signs of cutting or burns. Diagnostic results: None
Assessment
Mental Status Examination: Patti is a 40 year old Iranian female who is present for a family psychotherapy session and evaluation. She has a sad and annoyed tone, she reports feeling hopeless and lonely. She has recently been in individual therapy to reconcile her emotions about her disability and children support level in her life. She is alert and oriented to person, place, time, and situation, she has an appropriate thought process with clear and coherent speech. She is appropriately dressed and appears neatly groomed. Her speech is clear and coherent; no signs of tangent speech. She denies visual or auditory hallucinations, denies suicidal or homicidal ideations. During the interview, Patti identifies the problems that she has with her children, and relates her sadness to her children’s inability to support her in her time of need. Patti continuously becomes enraged by her children’s various inabilities to be cultural and attentive to her needs.
Differential Diagnoses:
1. Adjustment Disorder: Adjustment disorder begins three months within onset of a
stressor and lasts no longer than six months after the stressor as long as the stressor has
ceased. Criteria for a diagnosis of adjustment disorder is having the presence of
emotional or behavioral symptoms in response to an identifiable stressor; the stressor
may be a single event. multiple stressors, or recurrent or continuous stressors. The
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stressor may affect a single individual or entire family (American Psychiatric
Association, 2013). Patti was raised with Iranian values and based on traditional cultural
values attempts to project those expectations on her children. In a study, challenges
associated with sociocultural adjustment in a new country resulting from dissonance
between one’s culture of origin and the host culture (acculturative stress) are of poor
mental health. Family conflict was associated with poorer mental health and
psychological distress for immigrants. (Sangalang et al., 2019). Adjustment disorder is
the primary diagnosis for Patti, Patti consistently expresses her wish to have her children
be in her presence majority of the time, along with a wish for active involvement in her
children’s lives. Patti’s recent disability leaves her unable to engage in personal hobbies
and reliant on her children for companionship. This persistent stressor of having children
grow up and wanting independence causes an adjustment disorder for Patti, her
engagement in therapy with Sandi allows her to realize the cultural shifts occurring in her
family and her need to release control and adjust to the changing times.
2. Major Depressive Disorder: According to the DSM 5, MDD is present when five or
more of the selected symptoms are present during the same two week period. Symptoms
such as : depressed mood (signs of hopelessness, emptiness or sadness), loss of interest or
pleasure, insomnia or hypersomnia, psychomotor agitation or retardation , daily fatigue or
loss of energy the patient experiences, feelings of worthlessness or excessive or
inappropriate guilt, recurrent thoughts of death or suicidal ideations with or without a
plan (American Psychiatric Association, 2013). Patti displays primarily hopelessness, and
helplessness. Although she displays these symptoms, it is evident that she still expresses
interest in different tasks of pleasure, however, the primary issue is her physical disability
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and lack of support from her children. Patients who displays five of the diagnostic
symptoms of MDD, expressing signs of hopelessness, insomnia, fatigue, guilt and
worthlessness, suicidal ideations. This differential diagnosis is ruled out for Patti because
of her resolved underlying depression with individual therapy. Patients that met criteria of
MDD have distinguished levels of severity of MDD such as cognitive dysfunction, age,
psychosis, employment, and suicide ideation. (Tolentino and Schmnidt, 2018).
3. Generalized Anxiety Disorder: The DSM 5 defines GAD as anxiety or worrying about
having difficulty controlling worrying, excessive anxiety and worrying that occurs more
days than not for at least six months, symptoms such as restlessness, fatigue, irritability,
muscle tension, and muscle tension (American Psychological association, 2013). The
patient does not express fatigue, restlessness, or does not have excessive worrying about
her life or children; although she complains, she does not have excessive debilitating
uncontrolled anxiety or worrying over the actual current circumstance. The results of a
study utilizing the GAD-7 as a diagnostic tool referenced points that increased a patients
rating on the scale such as: the inability to sit still, or worrying about too many different
things (Jordan et al., 2017). Patti does not signify excessive worrying, inability to sit still,
or inability to stop worrying; therefore GAD would not be an appropriate primary
diagnosis for the patient.
Reflections: Ethical considerations for this patient is awareness of personal cultural
biases as well as clarification and identification of the client’s cultural biases and
hesitancies. The patient’s perceptions about the effectiveness of mental health services
and potential barriers to achievement of treatment goals should also be identified.
Cultural stereotypes might hinder the utilization of mental health services, due to fear of
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discrimination and devaluation (Bracke et al., 2019). If I were conducting this interview, I
would have had Patti expand on her childhood and explore dependence on other people.
Understanding Patti’s background will give me as the practitioner more insight into
Patti’s understanding of what a family is and how to tailor her individual and therapy
goals.
Case Formulation and Treatment Plan
Initiation of individual therapy for Patti once considering her disability and access to
transportation.
Time was allotted for questions and answers were provided. Provided supportive
listening. Client appeared to understand discussion and reflective team, but remains
hesitant to change. Client agrees to follow treatment regimen as discussed.
Follow up with psychiatrist as needed for medication adjustment, and weekly sessions.
Attend weight watchers sessions as discussed in the interview.
Recommendation for a competition of emotional intelligence testing. Rationale: Patti is
seemingly unaware of how her emotions impact her children. This test will give the client
insight into how to perceive, identify, understand, and manage her emotions.
Return to clinic in two weeks
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References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Bracke, P., Delaruelle, K., & Verhaeghe, M. (2019). Dominant Cultural and Personal Stigma
Beliefs and the Utilization of Mental Health Services: A Cross-National Comparison.
Frontiers in sociology. 4, 40. https://doi.org/10.3389/fsoc.2019.00040
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Jordan, P,., Shedden-Mora, M.C,., Löwe B. (2017) Psychometric analysis of the Generalized
Anxiety Disorder scale (GAD-7) in primary care using modern item response theory.
PLOS ONE. 12(8): https://doi.org/10.1371/journal.pone.0182162
Sangalang, C.C., Becerra, D., Mitchell, F.M. (2019). Trauma, Post-Migration Stress, and Mental
Health: A Comparative Analysis of Refugees and Immigrants in the United States. J
Immigrant Minority Health. 21, 909–919. https://doi.org/10.1007/s10903-018-0826-2
Tolentino, J., & Schmidt, S. (2018). DSM-5 Criteria and Depression Severity: Implications for
Clinical Practice. Front Psychiatry. https://doi.org/10.3389/fpsyt.2018.00450
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What TO DO
HOW TO CREATE A GENOGRAM USE THE WEBSITE BILLOW
https://www.therapistaid.com/therapy-guide/genograms
use this video for the case study
https://video-alexanderstreet-com.eu1.proxy.openathens.net/watch/mother-and-daughter-a-cultural-tale
AMILY ASSESSMENT
Assessment is as essential to family therapy as it is to individual therapy. Although families often present with one person identified as the “problem,” the assessment process will help you better understand family roles and determine whether the identified problem client is in fact the root of the family’s issues
To prepare:
· Review this week’s Learning Resources and reflect on the insights they provide on family assessment. Be sure to review the resource on psychotherapy genograms.
· Download the Comprehensive Psychiatric Evaluation Note Template and review the requirements of the documentation. There is also an exemplar provided with detailed guidance and examples.
· View the Mother and Daughter: A Cultural Tale video in the Learning Resources and consider how you might assess the family in the case study.
THE ASSIGNMENT
Document the following for the family in the video, using the Comprehensive Evaluation Note Template:
· Chief complaint
· History of present illness
· Past psychiatric history
· Substance use history
· Family psychiatric/substance use history
· Psychosocial history/Developmental history
· Medical history
· Review of systems (ROS)
· Physical assessment (if applicable)
· Mental status exam
· Differential diagnosis—Include a minimum of three differential diagnoses and include how you derived each diagnosis in accordance with DSM-5-TR diagnostic criteria
· Case formulation and treatment plan
· Include a psychotherapy genogram for the family
Note: For any item you are unable to address from the video, explain how you would gather this information and why it is important for diagnosis and treatment planning. NRNP/PRAC 6645 Comprehensive Psychiatric
