Assignment 2: comprehensive psychiatric evaluation note and patient

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 PLEASE FOLLOW INSTRCTION BELOW, ZERO PLAGIRISM, 7TH APA FORMAT, & SEE ATTACHED CASE STUDIES & TAMPLATE, FIVE REFERENCES  NOT MORE THAN  FIVE YEARS

Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Comprehensive psychiatric evaluation notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will document information about a patient that you examined in a group setting during the last 4 weeks, using the Comprehensive Psychiatric Evaluation Note Template provided. You will then use this note to develop and record a case presentation for this patient. 

To Prepare 

  • Review this week’s Learning Resources and consider the insights they provide about clinical practice guidelines. 
  • Select a group patient for whom you conducted psychotherapy for a mood disorder during the last 4 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide. All psychiatric evaluation notes must be signed, and each page must be initialed by your Preceptor. When you submit your note, you should include the complete comprehensive psychiatric evaluation note as a Word document and pdf/images of each page that is initialed and signed by your Preceptor. You must submit your note using SafeAssign.
    Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Grading Policy.
  • Then, based on your evaluation of this patient, develop a video presentation of the case. Plan your presentation using the Assignment rubric and rehearse what you plan to say. Be sure to review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
  • Include at least five scholarly resources to support your assessment and diagnostic reasoning.
  • Ensure that you have the appropriate lighting and equipment to record the presentation.

Patient is 64 y/o African American male with PMHX of Dementia, Schizophrenia, Weakness and General debility. He was seen for follow up. Patient still slightly symptomatic and will continue with adjusted Trazadone 100mg once a day at bed time. Nursing will continue to monitor for behavioral issues and document for follow up. During this visit, he was seen in Solarium with other peers. Acknowledge greetings from Provider by nodding his head. Verbalized no complain. He is cooperative, although he has reduced interaction with poor concentration and delay in his responses. Still not able to give any sensible information due to very substantial progressive cognitive impairment. Patients remain on Depakote 250 mg thrice daily. Will commence gradual drug reduction when stable. He is still quite symptomatic. Total ADLs care provided with one Person assist. No behavioral issue noted during this visit. He is stable clinically at his usual baseline. Fall and safety precaution maintained. He is being managed with Trazodone 100mg at bed time to aid with sleep and depression. Patient is benefitting from Depakote 250 mg thrice daily for mood stabilization and Ability 5mg daily for aggressive behavior/thoughts disorder and will continue with it. He has a good appetite and varied sleep. Alert and oriented x 1. He has poor insight, judgement, and concentration. Patient is compliant with treatment. Patient denies current SI/HI/AVH. Denies depressed or anxiety feelings.
Current Medication: As per Matrix medication lists for medical.
Psychiatric medication: Currently on Exelon 9.5 mg/24hr transdermal daily, Namenda XR 28 mg daily dementia, Trazodone 100mg daily for depression/ sleep. Depakote 250mg thrice daily and Abilify 5mg for aggression. Will continue with his current treatment regimen as the patient is still symptomatic. No GDR currently.
Past Psychiatric History: Yes
Past Psychiatric Hospitalization: Unknown
History of Suicide Attempts or Thoughts- Unknown
Previous Psychiatric Medications: None
PTSD: Y/N- Unknown.

Medical History/Review of Systems: See Matrix for medical diagnosis.
Allergies Drug: NKDA.
Food Allergies: NKFA
Surgery: Y/N- Unknown.

Sleep Pattern: Varied sleep.
Appetite: Normal

Mental Status Examination:

General Appearance: Neat & clean, casually dressed in good hygiene.
Eye contact: Normal.
Psychomotor Activity: Normal
Memory: Long term and short-term memory not intact, Has poor concentration.
Orientation: Person and Place (A/O X 1)
Attention: Reduced
SPEECH: Decreased speech in amount, rate, and volume .
MOOD: objectively Sad, guarded, suspicious, restricted and inappropriate.
AFFECT: Flat and anxious and not goal directed.
THOUGHT PROCESS: Not appropriate.
THOUGHT CONTENT: Denies SI/HI.
PERCEPTIONS: Denies AVH sensorium.
INSIGHT: Poor
JUDGMENT: Poor.
COGNITION: poor
Language :Normal.
Suicidal ideation/HI – Denies Suicidal or homicidal ideation.

SAFETY PLAN R

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 illn

NRNP/PRAC 6645 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:

(include psychiatric ROS rule out)

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:

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:

Differential Diagnoses:

Reflections:

Case Formulation and Treatment Plan:  

References

© 2021 Walden University

Page 3 of 3

Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Comprehensive psychiatric evaluation notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will document information about a patient that you examined in a group setting during the last 4 weeks, using the Comprehensive Psychiatric Evaluation Note Template provided. You will then use this note to develop and record a case presentation for this patient.

To Prepare

· Review this week’s Learning Resources and consider the insights they provide about clinical practice guidelines. 

· Select a group patient for whom you conducted psychotherapy for a mood disorder during the last 4 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide. All psychiatric evaluation notes must be signed, and each page must be initialed by your Preceptor. When you submit your note, you should include the complete comprehensive psychiatric evaluation note as a Word document and pdf/images of each page that is initialed and signed by your Preceptor. You must submit your note using SafeAssign.
Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Grading Policy.

· Then, based on your evaluation of this patient, develop a video presentation of the case. Plan your presentation using the Assignment rubric and rehearse what you plan to say. Be sure to review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.

· Include at least five scholarly resources to support your assessment and diagnostic reasoning.

· Ensure that you have the appropriate lighting and equipment to record the presentation.


The Assignment

Record yourself presenting the complex case study for your clinical patient. In your presentation: 

· Dress professionally with a lab coat and present yourself in a professional manner.  

· Display your photo ID at the start of the video when you introduce yourself.

· Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information). 

· Present the full complex case study. Be succinct in your presentation, and do not exceed 8 minutes. Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were r

Rubric Detail

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

Content

Name: PRAC_6645_Week4_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%) – 3 (3%)

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

Feedback:
Discuss Subjective data:
• Chief complaint
• History of present illness (HPI)
• Medications
• Psychotherapy or previous psychiatric diagnosis
• Pertinent histories and/or ROS

Points:

Points Range:
9 (9%) – 10 (10%)

The video accurately and concisely presents the patient’s subjective c

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