Prac 6645 – week 7_assignment 2: comprehensive psychiatric evaluation

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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:  


© 2021 Walden University

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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.


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 psychiatric assessment?


· Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms.


· Plan: Describe your treatment modality and your plan for psychotherapy. Explain the principles of psychotherapy that underline your chosen treatment plan to support your rationale for the chosen psychotherapy framework. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this psychotherapy session?

· Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.

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

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 illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)


CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why they are presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication, and referral reason. For example:

N.M. is a 34-year-old Asian male who presents for psychotherapeutic evaluation for anxiety. He is currently prescribed sertraline by (?) which he finds ineffective. His PCP referred him for evaluation and treatment.


P.H. is a 16-year-old Hispanic female who presents for psychotherapeutic evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her mental health provider for evaluation and treatment.

Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.

Paint a picture of what is wrong with the patient. This section contains the symptoms that is bringing the patient into your office. The symptoms onset, the duration, the frequency, the severity, and the impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders. You will complete a psychiatric ROS to rule out other psychiatric illnesses.

Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP.

General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13.

Caregivers are listed if applicable.

Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors?

Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it)

Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. (Or, you could document both.)

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.

Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information (be sure to include a reader’s key to your genogram) or write up in narrative form.

Psychosocial History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology. However, at a minimum, please include:

· Where patient was born, who raised the patient

· Number of brothers/sisters (what order is the patient within siblings)

· Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children?

· Educational Level

· Hobbies

· Work History: currently working/profession, disabled, unemployed, retired?

· Legal history: past hx, any current issues?

· Trauma history: Any childhood or adult history of trauma?

· Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)

Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries.

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).



Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudo hallucinations, illusions, etc.), cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.

He is an 8 yo African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking.   He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good. 

Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), social determinates of health, 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.).

Case Formulation and Treatment Plan.

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions with psychotherapy, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. *see an example below—you will modify to your practice so there may be information excluded/included—what does your preceptor document?


Initiation of (what form/type) of individual, group, or family psychotherapy and frequency.

Documentation of any resources you provide for patient education or coping/relaxation skills, homework for next appointment.

Client has emergency numbers: Emergency Services 911, the Client’s Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)

Reviewed hospital records/therapist records for collaborative information; Reviewed PCP report (only if actually available)

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (This relates to informed consent; you will need to assess their understanding and agreement.)

Follow up with PCP as needed and/or for:

Write out what psychotherapy testing or screening ordered/conducted, rationale for ordering

Any other community or provider referrals

Return to clinic:

Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care OR if one-time evaluation, say so and any other follow up plans.

References (move to begin on next page)

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

© 2021 Walden University

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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, he is wearing a

blue polo shirt and khaki shorts with his shoes. He has a longish black hair. He wears glasses. Attention is good. He is able to focus on the conversation.

· HEENT: Visual and auditory functions intact, no visual loss, no hearing difficulties, no ear discomfort. No sinus infection. No history of LOC or neck or head injury. No history of seizures or tremors.

· SKIN: Skin is intact, no rash or itching. Skin has no wounds, lesions, or hyperpigmentation. There are no signs of self-harm.

· CARDIOVASCULAR: No chest pain or chest discomfort. No edema was noted. The patient denies heart palpitations.

· RESPIRATORY: No breathing difficulty. Patient denies SOB.

· GASTROINTESTINAL: Normal bowel movements, no abdominal pain.

· GENITOURINARY: Urinary frequency is normal

· MUSCULOSKELETAL: No muscle or back pain.

· LYMPHATICS: No inflammation of lymph nodes.

· ENDOCRINOLOGIC: No endocrine issues.


Diagnostic results: The patients scores 13 on PHQ9, which shows moderate depression.


Mental Status Examination: The patient is alert and oriented to time, place, and situation. The patient is quite awake, attentive, and cooperative. The patient demonstrated good hygiene and dressed well for the event and weather. The speech is coherent but displays a depressed mood. His memory is intact and does not demonstrate any deficit. The patient reports being anxious due to his financial situation currently. The patient does not show evidence of mania, psychosis, or anxiety. 

Differential Diagnoses:

Bipolar Disorder

The patient had a history of depressive moods, although he has demonstrated slight improvements. The patient also has a history of depressive disorder and is currently feeling anxious. Bipolar is associated with changing moods, which the patient has reported to have improved over the week. The patient is also said to have attempted suicide, which is common for patients with bipolar illness (Miller & Black, 2020).

Attention Deficit Disorder

The disorder commonly known as ADHD is a neurodevelopmental disorder and primarily affects the youths but can manifest even in adults. Some of the significant symptoms of the condition include aggression, repetition of actions, and generally poor concentration (Ewe, 2019). The patient demonstrates decreased attention, as demonstrated in the case that his attention was average, which means he was not attentive as it would have been required.

Wilson Disease

The condition is caused by the increased accumulation of copper in the brain and the eyes. The disease can be presented in the form of increased anxiety, mood swings, and the manifestation of depressive symptoms, which are evident in the patient (Aggarwal & Bhatt, 2018).

The patient is most likely to be assessed further for Bipolar disorder.


One thing I would do differently is to include the patient’s medication history. The patient has been hospitalized due to a medication overdose, but the type of medication was not included in the patient medical history during an evaluation. One consideration I would make during psychiatric therapy for patients with mental disorders is the impact of poverty and the inability to access quality mental health services. As a future mental health practitioner, it is essential to focus on mental health awareness in poverty-stricken regions to foster their ability to access mental health assessments and overall mental health awareness. It is crucial to carry out mental health education campaigns to ensure they understand the importance of mental health. Reaching out to rural communities and education promotes mental health awareness and reduces disparities in mental health access (Healthy People 2030). Psychological disorders require counseling therapy more than medical therapy. However, medication is essential because it helps a patient recover from their conditions, but the patient can have compliance issues that affect the overall effectiveness of the ordered therapy. Medication is the best treatment for mood disorders, but non-compliance may not serve any good for the client. The patient requires interdisciplinary therapy because of his previous treatment and the manifestation of mixed symptoms of depressive and mood disorders (McKee et al., 2018). However, some critical details that could have helped make more informed treatment decisions, like availing the patient’s social life, are lacking. Social life and conduct demonstrate the mental status of a patient. This would help understand the issue, which is instrumental in a therapeutic process.

Case Formulation and Treatment Plan:  

The patient must be educated on avoiding triggering factors such as alcohol and drug use. Moreover, the patient can also be advised to eat a balanced diet and engage in exercise activities. This would help the patient fight depressive moods that might eventually escalate to a more severe condition (Antony & Barlow, 2020).

The patient should be educated on detecting early signs of depression and which strategies they should adopt once they discover mood changes. The patient may also be advised to take note of their depressive moods to ensure they are doing well and identify any changes that may be occurring (Antony & Barlow, 2020). This can be done effectively by having a journal entry to record their experiences.

The patient should also be taught on the values of self-worth and coping strategies they need to adopt to improve their self-esteem to avoid developing anxiety over things they have or do not have control over (Antony & Barlow, 2020). This will help prevent undue stigma and eventually achieve better results.

Treatment and Management

Medication is the primary treatment for bipolar disorder. The patient can be recommended for medication to modify and stabilize their moods. Mood stabilizers ensure the symptoms are kept under control and ensure extremes of the bipolar disease are managed. In the case of ADHD. The patient can be ordered for stimulants, while the anxiety symptoms can be treated using SSRIs and antidepressants (Antony & Barlow, 2020).

The patient is more recommended for psychotherapeutic treatment. The most appropriate therapy is cognitive-behavioral therapy (CBT) in the treatment of related mental illness, which includes anxiety and bipolar (Antony & Barlow, 2020). The patient needs to learn how to handle experiences that are not appealing or are causing fear, such as financial uncertainties. The patient needs to be educated on how he should handle his moods and manage stress with the assistance of a therapist.

The patient should be educated on handling symptoms associated with the disease. This will help avoid complications associated with the disease. The patient can be taught to identify common symptoms associated with bipolar disorder and how they should handle such symptoms to prevent the disease-causing serious complications (Antony & Barlow, 2020).

The patient should also be educated on how to manage their lifestyle to manage their moods. They can be taught the importance of having a good and regular sleep, avoiding alcohol and drugs, eating a good diet, exercising regularly, and overall maintenance of personal wellbeing.

The patient also needs to have a reliable source of support. Mental conditions have devastating experiences, and providing a patient with a support network maintains their motivation. The patient is allowed to share their experiences and also get the education and advice from people that might have experienced similar challenges in their lives (Antony & Barlow, 2020). The patient needs to know he is not a burden to people around him and can always rely on them for support.


Aggarwal, A., & Bhatt, M. (2018). Advances in treatment of Wilson disease. Tremor and Other Hyperkinetic Movements8.

Antony, M. M., & Barlow, D. H. (Eds.). (2020). Handbook of assessment and treatment planning for psychological disorders. Guilford Publications.

Ewe, L. P. (2019). ADHD symptoms and the teacher–student relationship: a systematic literature review. Emotional and Behavioural Difficulties24(2), 136-155.

Healthy People 2030. Healthy People Partners and SDOH.

McKee, K., Glass, S., Adams, C., Stephen, C. D., King, F., Parlman, K., … & Kontos, N. (2018). The inpatient assessment and management of motor functional neurological disorders: an interdisciplinary perspective. Psychosomatics59(4), 358-368.

Miller, J. N., & Black, D. W. (2020). Bipolar disorder and suicide: a review. Current psychiatry reports22(2), 1-10.

© 2021 Walden University

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