Please review the complete instructions. Also review and follow the exemplar to complete the assignment on the provided template.

(Male,45, Mood Disorder) 

A 45-year-old patient with a history of Depression disorder and previous suicidal attempts. Patient last hospitalization was two months ago after a failed suicide attempt by overdose, the patient was in the hospital for eight days; today is his fourth session after discharge. During the nursing assessment, the patient appears awake, alert, and oriented x3, he manifested feeling anxious due to some financial issues, otherwise manifested having no prominent symptoms of depression, anxiety, mania, or psychosis. In the session carried out today, the patient appeared calm, friendly, communicative, and relaxed. His participation today was average. After completing today’s activities, the patient showed improvements in relaxation through psychotherapy. The patient was active and participated fully in discussions today. The patient reports that his mood has improved in the past two weeks, and that he feels hopeful and with plans for the future. During the session, the clinician facilitated a discussion about stress management techniques. Psychoeducation provided regarding clarifying areas of difficulty and identifying coping skills. The clinician provided psychoeducation regarding medication compliance, and the patient was receptive. The patient was encouraged to continue follow-up psychotherapy to monitor his anxiety. Individual psychotherapy schedule in 4 weeks.


Assignment 2: Comprehensive Psychiatric Evaluation Note

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 (See above), using the Comprehensive Psychiatric Evaluation Note Template provided.


Instructions:

Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided. There is also a completed template provided as an exemplar and guide.

Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.

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

· Objective: What observations did you make during the psychiatr

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 1 of 3