NRNP PRAC 6645 Comprehensive Psychiatric Evaluation Template

Sample Answer for NRNP PRAC 6645 Comprehensive Psychiatric Evaluation Template Included After Question

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 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.)

EXEMPLAR BEGINS HERE

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.

Or

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).

Assessment

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?

Example:

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.

A Sample Answer For the Assignment: NRNP PRAC 6645 Comprehensive Psychiatric Evaluation Template

Title: NRNP PRAC 6645 Comprehensive Psychiatric Evaluation Template

NRNP PRAC 6645 Comprehensive Psychiatric Evaluation Template

Week (enter week #): Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

Subjective:

CC (chief complaint): ‘I am afraid to go to the rehab.’

HPI: Lisa Pittman is a 29-year-old female that has come to the unit for treatment for Hep C+ and needs to get clean first. She is thinking of going for long-term rehab but is fearful of what people will say and the perception that they are dirty. Lisa has been smoking crack cocaine, approximately $1000 daily, cannabis 1-2 times weekly, and 2-3 alcoholic drinks weekly. She also has a history of theft convictions and drug possessions and is on a 2-year probation with randomized drug screens. Her laboratory values have demonstrated abnormal results in ALT, AST, bilirubin, albumin, GGT, and positive for cocaine. She has a history of sexual abuse as a child, with perpetrator being her father who was imprisoned for the offence and drug charges. Lisa is currently in a relationship with Jeremy, who also abuses drugs and alcohol. She has a daughter who lives with her friends.

Past Psychiatric History:

• General Statement: I am afraid of going to the rehab
• Caregivers (if applicable): none
• Hospitalizations: Lisa denied any history of hospitalizations
• Medication trials: Lisa denied any history of medication trials
• Psychotherapy or Previous Psychiatric Diagnosis: Lisa denied any history of psychotherapy or previous psychiatric diagnosis

Substance Current Use and History: Lisa currently abuses cannabis 1-2 times weekly, smokes crack cocaine, and drinks 2-3 alcoholic drinks weekly

Family Psychiatric/Substance Use History: There is history of substance abuse in Lisa’s family. Her father was imprisoned for sexually abusing her and drug offenses. Her mother has a history of benzodiazepine use. Her older brother has history of opioid abuse. Her mother has a history of anxiety.

Psychosocial History: Lisa is not married. She is in a relationship with Jeremy. She current works and struggles to remain clean so that people do not talk about her. She has a daughter who stays with her friends.

Click here to ORDER an A++ paper from our Verified MASTERS and DOCTORATE WRITERS NRNP PRAC 6645 Comprehensive Psychiatric Evaluation Template:

Medical History: Lisa denied any history of hospital admission, surgeries, or blood transfusion.

• Current Medications: Lisa is not currently using any medications
• Allergies: She is allergic to Amoxicillin. She denied other forms of allergies.
• Reproductive Hx:Her menarche was when she was 15 years. Her last menstrual period was one week ago. She is currently not using any contraceptive method. She denies any menstrual problems. She is sexually active. She does not use any protection when engaging in sexual intercourse. She has one child. She denied any history of pregnancy loss. She denied history of sexually transmitted infections. She denied dysuria, urgency, and frequency. She was sexually abused when she was aged 5-7 by her father.

ROS:

• GENERAL: Lisa appears poorly groomed for the occasion. She is slightly underweight for her age. She does not demonstrate restlesses, agitation, and denies fever
• HEENT: Eyes: Lisa denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: She also denies hearing loss, sneezing, congestion, runny nose, or sore throat.
• SKIN: Lisa denies rash or itching. There are evident needle prick marks on the arms.
• CARDIOVASCULAR: Lisa denies chest pain, chest pressure, or chest discomfort. She also denies palpitations or edema.
• RESPIRATORY: Lisa denies shortness of breath, cough, or sputum.
• GASTROINTESTINAL: She denies anorexia, nausea, vomiting, or diarrhea. She also denies abdominal pain or blood. She reports decline in appetite. She prefers getting higher to eating.
• GENITOURINARY: Lisa denies burning on urination, urgency, hesitancy, odor, odd color
• NEUROLOGICAL: Lisa denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. She also denies change in bowel or bladder control.
• MUSCULOSKELETAL: Lisa denies muscle, back pain, joint pain, or stiffness.
• HEMATOLOGIC: Lisa denies anemia, bleeding, or bruising.
• LYMPHATICS: She denies enlarged nodes. No history of splenectomy.
• ENDOCRINOLOGIC: She denies reports of sweating, cold, or heat intolerance. She also denies polyuria or polydipsia.

Objective:

Physical exam: if applicable

Diagnostic results: laboratory investigations were ordered. The labs were abnormal for ALT 168, AST 200, ALK 250, bilirubin 2.5, albumin 3.0, GGT 59, and UDS positive for cocaine. The labs were negative for alcohol or other drugs. BAL o; other labs within normal range.

Assessment:

Mental Status Examination: Lisa is poorly groomed for the occasion. She is oriented to self, time, place, and events. She maintains normal eye contact during the assessment. Her speech is normal in terms of tone, volume, and rate. She does not demonstrate tics or tremors during the assessment. She responds appropriately to questions. She denies illusion, delusion, and hallucinations. Her thought content is future oriented. She denies suicidal thoughts, attempts, or plans. Her mood is flat with constricted affect.

Differential Diagnoses:

Lisa’s primary diagnosis is substance use disorder. According to DSM5, substance use disorders are mental health problems that arise from the abuse of drugs that include alcohol, caffeine, cannabis, hallucinogens, opioids, hypnotics, stimulants, tobacco, and sedatives. Prolonged use of these drugs result in substance use disorders where patients continue using them despite experiencing problems associated with them (Jones & McCance-Katz, 2019). DMS5 has developed criteria that practitioners utilize in diagnosing patients with substance use disorders. One of them is an individual taking a substance in larger amounts and for longer periods than it was intended. It also includes individuals having the intention to stop or cut down using the substance but he/she is unable. The additional symptoms include spending a lot of time in acquiring, using, or recovering from the substance and having immense cravings and urges to use it. Substance use also affects the normal functioning of its users. In addition, the users continue abusing them even it they cause problems in their lives or relationships (Arterberry et al., 2020). Substance use disorder patients also require more of the drug to achieve the effect they want, develop withdrawal symptoms when they abstain, and continue using the substance even if they are experiencing adverse health problems. Overall, the above symptoms can be classified into broad categories that include social problems, impaired contro, risky substance use, and physical dependence (Basedow et al., 2020). Lisa’s problems align with the above. For example, she reports using crank cocaine, smoking, and alcohol despite knowing its effects. She also spends a significant amount and time to get the substances she needs. She also has developed tolerance since she has to take the substances for her to feel high. As a result, substance use disorder is her primary diagnosis.

One of Lisa’s secondary diagnoses is post-traumatic stress disorder. Post-traumatic stress disorder is a mental disorder that arises from one’s exposure or experience of a traumatic event. The trauma predisposes them to developing symptoms such avoidance behaviors, depressed mood, flashbacks, and nightmares about their experiences (Bryant-Genevier et al., 2021; Maercker et al., 2022). Lisa has a history of being abused sexually when she was a child. As a result, she is at a risk of developing post-traumatic stress disorder. However, it is the least likely diagnosis at this stage since she does not demonstrate symptoms of the disorder such as avoidance, flashbacks, and depressed mood among others.

The last potential diagnosis that should be considered for Lisa is major depression. Major depression is a mental disorder characterized by severly depressed mood, anhedonia, social withdrawal, feelings of hopelessness, and guilt. Patients also report changes in sleep, appetite, and weight, suicidal thoughts, attempts, or plans, and poorly functioning in their social and occupational roles. Depression may be attributed to causes such as social stressors as well as substance abuse (Rice et al., 2019). However, Lisa does not demonstrate the symptoms of major depression such as depressed mood, anhedonia, and feelings of guilt and hopelessness. Therefore, major depression is the least likely cause of her mental health problem.

Reflections: I agree with the preceptor’s assessment and diagnostic impression. Lisa’s diagnosis of substance use disorder is accurate based on the criteria developed by DSMV. I learned some aspects related to mental health practice from this case study. One of them is conducting comprehensive patient assessment and psychiatric assessment. I also learned about the consideration of potential differential diagnoses and narrowing to a specific diagnosis that relates to the patient’s problem. Ethical considerations such as patient autonomy, justice, confidentiality, and privacy should guide the treatment of psychiatric patients. Social determinants such as socioeconomic status should be investigated to understand their influence on mental health problems.

References

Arterberry, B. J., Boyd, C. J., West, B. T., Schepis, T. S., & McCabe, S. E. (2020). DSM-5 substance use disorders among college-age young adults in the United States: Prevalence, remission and treatment. Journal of American College Health, 68(6), 650–657. https://doi.org/10.1080/07448481.2019.1590368

Basedow, L. A., Kuitunen-Paul, S., Roessner, V., & Golub, Y. (2020). Traumatic Events and Substance Use Disorders in Adolescents. Frontiers in Psychiatry, 11. https://www.frontiersin.org/articles/10.3389/fpsyt.2020.00559

Bryant-Genevier, J., Rao, C. Y., Lopes-Cardozo, B., Kone, A., Rose, C., Thomas, I., Orquiola, D., Lynfield, R., Shah, D., Freeman, L., Becker, S., Williams, A., Gould, D. W., Tiesman, H., Lloyd, G., Hill, L., & Byrkit, R. (2021). Symptoms of Depression, Anxiety, Post-Traumatic Stress Disorder, and Suicidal Ideation Among State, Tribal, Local, and Territorial Public Health Workers During the COVID-19 Pandemic—United States, March–April 2021. Morbidity and Mortality Weekly Report, 70(26), 947–952. https://doi.org/10.15585/mmwr.mm7026e1

Jones, C. M., & McCance-Katz, E. F. (2019). Co-occurring substance use and mental disorders among adults with opioid use disorder. Drug and Alcohol Dependence, 197, 78–82. https://doi.org/10.1016/j.drugalcdep.2018.12.030

Maercker, A., Cloitre, M., Bachem, R., Schlumpf, Y. R., Khoury, B., Hitchcock, C., & Bohus, M. (2022). Complex post-traumatic stress disorder. The Lancet, 400(10345), 60–72. https://doi.org/10.1016/S0140-6736(22)00821-2

Rice, F., Riglin, L., Lomax, T., Souter, E., Potter, R., Smith, D. J., Thapar, A. K., & Thapar, A. (2019). Adolescent and adult differences in major depression symptom profiles. Journal of Affective Disorders, 243, 175–181. https://doi.org/10.1016/j.jad.2018.09.015