Assessing and diagnosing patients with neurocognitive and

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 Neurodevelopmental disorders begin in the developmental period of childhood and may continue through adulthood. They may range from the very specific to a general or global impairment, and often co-occur (APA, 2013). They include specific learning and language disorders, attention deficit hyperactivity disorder (ADHD), autism spectrum disorders, and intellectual disabilities. Neurocognitive disorders, on the other hand, represent a decline in one or more areas of prior mental function that is significant enough to impact independent functioning. They may occur at any time in life and be caused by factors such brain injury; diseases such as Alzheimer’s, Parkinson’s, or Huntington’s; infection; or stroke, among others. 

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar

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 assignment in Weeks 4–10. After reviewing the 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: Discuss 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 demonstrat

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

Week (enter week #): (Enter assignment title)

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

Faculty Name

Assignment Due Date

Subjective:

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:

Objective:

Physical exam: if applicable

Diagnostic results:

Assessment:

Mental Status Examination:

Differential Diagnoses:

Reflections:

References

© 2021 Walden University Page 1 of 3

Neurocognitive and Neurodevelopmental Disorders

Training Title 48

Name: Sarah Higgins

Gender: female

Age: 9 years old

T- 97.4 P- 62 R 14 95/60 Ht. 4’5 Wt. 63lbs

Background: no history of treatment, developmental milestones met on time, vaccinations up

to date. Sleeps 9hrs/night, meals are difficult as she has hard time sitting for meals, she does

get proper nutrition per PCP.

Symptom Media. (Producer). (2017). Training title 48 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-48

BEGIN TRANSCRIPT: TRAINING TITLE 48

OFF CAMERA Well, thank you for bringing in these completed questionnaires on attention deficit hyperactivity disorder. 

MRS. HIGGINS Yeah, you asked me to have some of her teachers fill out the forms, and so, I had two, and I filled out one. 

OFF CAMERA Great, great, that’s wonderful, and these look very, yep, very completely filled out. How are you today, Sarah? 

SARAH Fine, thank you. 

OFF CAMERA Is it okay if I ask you some of the questions about how well you pay attention in school? 

SARAH Uh-huh. 

MRS. HIGGINS Sarah, use full words. 

00:00:55 SARAH Yes, sir. 

OFF CAMERA You are very polite. Thank you. Some people your age have difficulty being polite. You are very polite. When teachers tell you assignments in school, how well do you remember what they said your assignments are? 

SARAH Not very well. 

OFF CAMERA Mm-hmm. 

SARAH, they have to write her down a list. 

OFF CAMERA Okay. Does that list help? 

SARAH Sometimes I lose the list. 

OFF CAMERA Oh, do you forget where you put the list of assignments? 

SARAH Uh-huh. I mean, yes, I forget. 

OFF CAMERA Does that happen every time or sometimes or not very much? 

SARAH, it happens sometimes. 

MRS. HIGGINS Actually, every day. 

OFF CAMERA Okay. Do you think maybe your mom is right about that, that you forget your assignment list almost every day? 

SARAH Yes. 

MRS. HIGGINS Yeah, they have to leave me a list on my cell phone. 

OFF CAMERA Oh, okay. How long has this been a problem? 

MRS. HIGGINS Pretty much since she started school, kindergarten. 

OFF CAMERA Uh-huh, let’s see what else is on this list. How well do you sit still in your chair at school? 

SARAH Not very well. 

OFF CAMERA Uh-huh, do you fidget? 

SARAH (chuckles) Yes. 

OFF CAMERA Do you get in trouble for fidgeting or getting out of your chair? 

ARAH Sometimes. 

OFF CAMERA Okay, and if you’re reading from a book or a paper, can you sit still then and read? 

SARAH S

Rubric Detail

Select Grid View or List View to change the rubric’s layout.

Content

Name: PRAC_6635_Week9_Assignment2_Rubric

  Excellent Good Fair Poor
Photo ID display and professional attire

Points:

Points Range:
5 (5%) – 5 (5%)

Photo ID is displayed. The student is dressed professionally.

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

Photo ID is not displayed. Student must remedy this before grade is posted. The student is not dressed professionally.

Feedback:
Time

Points:

Points Range:
5 (5%) – 5 (5%)

The video does not exceed the 8-minute time limit.

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

The video exceeds the 8-minute time limit. (Note: Information presented after the 8 minutes will not be evaluated for grade inclusion.)

Feedback:
Description of chief complaint and history of present illness

Points:

Points Range:
5 (5%) – 5 (5%)

The student provides an accurate, clear, and complete description of the chief complaint and history of present illness.

Feedback:

PLEASE FOLLOW THE INSTRUCTIONS AS INDICATED BELOW:

1). ZERO (0) PLAGIARISM

2). AT LEAST 5 REFERENCES, NO MORE THAN 5 YEARS.

3). PLEASE SEE THE ATTACHED RUBRIC DETAILS. Instruction, Comprehensive Psychiatric Evaluation Template/Exemplar, Patient’s background/History

4). Follow the APA 7 writing style/format.

Assignment: Assessing and Diagnosing Patients With Neurocognitive and Neurodevelopmental Disorders

Neurodevelopmental disorders begin in the developmental period of childhood and may continue through adulthood. They may range from the very specific to a general or global impairment, and often co-occur (APA, 2013). They include specific learning and language disorders, attention deficit hyperactivity disorder (ADHD), autism spectrum disorders, and intellectual disabilities. Neurocognitive disorders, on the other hand, represent a decline in one or more areas of prior mental function that is significant enough to impact independent functioning. They may occur at any time in life and be caused by factors such brain injury; diseases such as Alzheimer’s, Parkinson’s, or Huntington’s; infection; or stroke, among others.

For this Assignment, you will assess a patient in a case study who presents with a neurocognitive or neurodevelopmental disorder.

To Prepare:

· Review this week’s Learning Resources and consider the insights they provide. Consider how neurocognitive impairments may have similar presentations to other psychological disorders.

· Review the Comprehensive Psychiatric Evaluation template, which you will use to complete this Assignment.

· By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.

· Consider what history would be necessary to collect from this patient.

· Consider what interview questions you would need to ask this patient.

· Identify at least three possible differential diagnoses for the patient.

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.
Incorporate the following into your responses in the template:

· Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life? 

· Objective: What observations did you make during the psychiatric assessment?  

· Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest 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. E

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