Please review the complete instructions and use the template to complete the assignment.

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


CC (chief complaint):


(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:



Diagnostic results:


Mental Status Examination:

Differential Diagnoses:


Case Formulation and Treatment Plan:  


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Assignment 2: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation

Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. 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 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. 

Case study:

(Female, 16, Anxiety Disorder, (DMDD) Disruptive mood dysregulation disorder)

16-years-old Afro-American female with history of DMDD and sickle cell disease. Patient is accompanied by her foster mother. Today is patient’s fifth visit to the clinic. Patient has a long history of mental hospitalizations as well as medical admissions. Patient last admitted to the hospital was 3 weeks ago for three days as she had a sickle cell crisis.

Patient was removed from his parents at the age of 6 due to negligence and physical abuse. Foster mother report that she is ‘uncontrollable” at home and when thing doesn’t going her way she destroyed dishes and furniture. Patient had been running away from home twice in the past year. 2 years ago she was found playing with the gas stove and started a small fire. She likes to play rude and pulls the family cat around by its tail. Patient has been in two different foster homes, the last one since she was 11 years old. The foster mother described a several-year history of aggressive and destructive behavior as well as four school suspensions during the past year.

On today’s session patient is well dress, AAO x 3, seems distracted and without interest of answer questions or participate. Patient denies suicidal or homicidal ideations, intentions or plan, also denies auditory, visual or tactile hallucinations. As per foster mother, patient is being disrespectful and restless at home. She also report that the patient is starting fights at school with her peers. Patient refused to talk about it. During the session, the clinician facilitated a discussion about stress management and impulse control techniques. Psychoeducation provided regarding clarifying areas of difficulty and identifying coping skills. The clinician provided psychoeducation regarding medication compliance, and patient / caregiver were receptive. The patient was encouraged to continue follow-up psychotherapy to monitor her mood. Individual psychotherapy is scheduled for next week.



NRNP/PRAC 6645 Comprehensive Psychiatric

Evaluation Note Template


If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template
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


· 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

Week #4: Assignment 2: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation

Ariel Cordova Lopez

College of Nursing-PMHNP, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

Dr. Suhad Sadik

June 26, 2022


CC (chief complaint): The patient is feeling anxious due to financial issues.

HPI: A 45-year-old male presents to the clinic for regular assessment. The patient has a history of depressive disorder and suicidal attempts through overdose. The patient reports having anxiety due to financial issues. The patient is currently responding well to the current medication.

Past Psychiatric History:

· General Statement: The patient had a history of depressive disorder and was hospitalized for a suicide attempt two months ago by overdose.

· Caregivers (if applicable): NA – Patient lives by himself.

· Hospitalizations: The patient was hospitalized two months ago for attempted suicide through overdose. Patient was in the hospital for eight days.

· Medication trials: The patient has not participated in medication trials.

· Psychotherapy or Previous Psychiatric Diagnosis: The patient does have a history of substance use in his early twenties: substance use, marijuana, and crack. The patient doesn’t use substances currently.

Substance Current Use and History: The patient does have a history of substance use in his early twenties. Substance use, marijuahna and crack. Patient doesn’t use substance currently.

Family Psychiatric/Substance Use History: The patient’s mother with a history of Bipolar Disorder. Unknown history of substance use in the family.

Psychosocial History: The patient is a 45-year-old Hispanic male, born and raised in Cuba, who moved to Miami at the age of 16. His higher level of education is high school. The patient was married once and had a daughter that lives out of the state with her mother. Currently patient lives by himself in a shared room. The patient is presently unemployed. His last job was as a UPS driver. He is receiving SSI, and unemployment. The patient is now looking for a job.

Medical History: The patient had been treated previously after a suicide attempt for overdose. The type of medication is not known.

· Current Medications: Patient was discharged from the hospital with Prozac 20 mg PO QAM and Zyprexa 10mg PO QHS.

· Allergies: The patient is allergic to Iodine.

· Reproductive Hx: The patient has a daughter but doesn’t have contact with her; she lives out of state.


· GENERAL: Appears stated age, clothing is appropriated for the season,