For this Assignment, you will document information about a patient that you examined at your practicum site, 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 impulse-control and conduct disorders.
- Select a patient for whom you conducted psychotherapy for an impulse control or conduct disorder during the last 6 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 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.
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
1
Week 7: Impulse Control Disorder
Lori Sfakios
College of Nursing-PMHNP, Walden University
NRNP 6645: Psychotherapy with Multiple Modalities Practicum
Dr. Lavon Williams
October 13, 2021
2
Impulse Control Disorders
Impulse control disorders are a category of disorders that involve the inability to control
emotions and behaviors. And is most evident through impulsive aggression. Disorders in this
category include intermittent explosive disorder, kleptomania, pyromania, oppositional defiance
disorder, and conduct disorder. Intermittent explosive disorder (IED) is an example that consists
of a person’s inability to control their emotions. Intermittent explosive disorder is marked by
significant psychosocial dysfunction (Patoilo et al., 2021). Serotonin function has shown to be
altered in clients with IED when compared with healthy controls (Coccaro and Grant, 2019).
Patoilo et al. (2021) were able to further support IED as a diagnosis due to the results of their
study that significantly showed a higher response of anger by those diagnosed with IED than
healthy controls and psychiatric controls. The results of their study aligned with the premise that
persons with IED are more likely to misinterpret a social situation and exhibit anger than those
without IED. The purpose of this assignment is to complete a psychiatric evaluation and
formulate a treatment plan for a client who has the diagnosis of IED
3
CC: “I just need to stay sober. I am lonely and that gets me into trouble”
HPI: Client is a 63 male diagnosed with major depressive disorder, unspecified (F33.9),
generalized anxiety disorder (F41.1), opioid use disorder, severe (F11.20), and intermittent
explosive disorder (F63.81). He was referred to group therapy by his primary care provider
(PCP). He is currently participating in a methadone treatment program and is permitted to take
home his weekly supply of bottles. He was recently asked to bring his bottles in for a recall, and
he could not bring in his unused doses as he had been taking more than he should. He was honest
about his misuse and reported feeling depressed. He states, “I was feeling depressed after a
breakup, and I was taking extra methadone to see if it would help my mood, but it didn’t.” He
reports increasing anger due to the breakup and states, “My temper gets me in trouble. I pushed
my girlfriend away because I get jealous and angry.” He is currently on a selective serotonin
reuptake inhibitor (SSRI) for his depression and has been on weekly group psychotherapy but
would like individual therapy. He denies suicidal and homicidal ideations, auditory and visual
hallucinations.
Past Psychiatric History
For this Assignment, you will document information about a patient that you examined at your practicum site, using the Comprehensive Psychiatric Evaluation Note Template provided. You will then use this note to develop and record a case presentation for this patient.
Make up as patient it cannot be the same as in this paper. This paper must be different rewritten altogether different references everything
To Prepare
· Review this week’s Learning Resources and consider the insights they provide about impulse-control and conduct disorders.
· Select a patient for whom you conducted psychotherapy for an impulse control or conduct disorder during the last 6 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 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
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