6/14/2021
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Name: NRNP_6635_Week4_Assignment_Rubric
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Create
documentation in the
Comprehensive
Psychiatric
Evaluation Template
about the patient you
selected.
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
Excellent
Good
Fair
Poor
18 (18%) - 20
16 (16%) - 17
14 (14%) - 15
0 (0%) - 13 (13%)
The response
throughly and
accurately
describes the
patient's
subjective
complaint,
history of
present illness,
past
psychiatric
history,
medication
trials and
current
medications,
psychotherapy
or previous
psychiatric
diagnosis,
pertinent
histories,
allergies, and
review of all
systems that
would inform a
differential
diagnosis.
The response
accurately
describes the
patient's
subjective
complaint,
history of
present
illness, past
psychiatric
history,
medication
trials and
current
medications,
psychotherapy
or previous
psychiatric
diagnosis,
pertinent
histories,
allergies, and
review of all
systems that
would inform
a differential
diagnosis.
The response
describes the
patient's
subjective
complaint,
history of
present illness,
past psychiatric
history,
medication
trials and
current
medications,
psychotherapy
or previous
psychiatric
diagnosis,
pertinent
histories,
allergies, and
review of all
systems that
would inform a
differential
diagnosis, but
is somewhat
vague or
contains minor
innacuracies.
(20%)
(17%)
(15%)
The response
provides an
incomplete or
inaccurate
description of
the patient's
subjective
complaint,
history of
present illness,
past
psychiatric
history,
medication
trials and
current
medications,
psychotherapy
or previous
psychiatric
diagnosis,
pertinent
histories,
allergies, and
review of all
systems that
would inform a
differential
diagnosis. Or,
subjective
documentation
is missing.
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Excellent
Good
Fair
Poor
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.
18 (18%) - 20
16 (16%) - 17
14 (14%) - 15
0 (0%) - 13 (13%)
The response
thoroughly and
accurately
documents the
patient's
physical exam
for pertinent
systems.
Diagnostic
tests and their
results are
thoroughly and
accurately
documented.
The response
accurately
documents
the patient's
physical exam
for pertinent
systems.
Diagnostic
tests and their
results are
accurately
documented.
Documentation
of the patient's
physical exam
is somewhat
vague or
contains minor
innacuracies.
Diagnostic
tests and their
results are
documented
but contain
minor
innacuracies.
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 criticalthinking process that
led you to the
primary diagnosis
you selected. Include
pertinent positives
and pertinent
negatives for the
specific patient case.
23 (23%) - 25
20 (20%) - 22
18 (18%) - 19
(20%)
(25%)
The response
thoroughly and
accurately
documents the
results of the
mental status
exam.
Response lists
at least three
distinctly
different and
detailed
possible
disorders in
order of
priority for a
differential
diagnosis of
the patient in
the assigned
case study, and
it provides a
thorough,
accurate, and
detailed
justification for
each of the
disorders
selected.
(17%)
(22%)
The response
accurately
documents
the results of
the mental
status exam.
Response lists
at least three
distinctly
different and
detailed
possible
disorders in
order of
priority for a
differential
diagnosis of
the patient in
the assigned
case study,
and it provides
an accurate
justification
for each of the
disorders
selected.
(15%)
(19%)
The response
documents the
results of the
mental status
exam with
some
vagueness or
innacuracy.
Response lists
at least three
different
possible
disorders for a
differential
diagnosis of
the patient and
provides a
justification for
each, but may
contain some
vaguess or
innacuracy.
The response
provides
incomplete or
inaccurate
documentation
of the patient's
physical exam.
Systems may
have been
unnecessarily
reviewed, or,
objective
documentation
is missing.
0 (0%) - 17 (17%)
The response
provides an
incomplete or
inaccurate
description of
the results of
the mental
status exam
and
explanation of
the differential
diagnoses. Or,
assessment
documentation
is missing.
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Excellent
Good
Fair
Poor
Reflect on this case.
Discuss 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.).
9 (9%) - 10 (10%)
8 (8%) - 8 (8%)
7 (7%) - 7 (7%)
0 (0%) - 6 (6%)
Reflections are
thorough,
thoughtful,
and
demonstrate
critical
thinking.
Reflections
demonstrate
critical
thinking.
Reflections are
somewhat
general or do
not
demonstrate
critical
thinking.
Reflections are
incomplete,
inaccurate, or
missing.
Provide at least three
evidence-based, peerreviewed journal
articles or evidencedbased guidelines that
relate to this case to
support your
diagnostics and
differential
diagnoses. Be sure
they are current (no
more than 5 years
old).
14 (14%) - 15
12 (12%) - 13
11 (11%) - 11
0 (0%) - 10 (10%)
(15%)
The response
provides at
least three
current,
evidencebased
resources from
the literature
to support the
assessment
and diagnosis
of the patient
in the assigned
case study. The
resources
reflect the
latest clinical
guidelines and
provide strong
justification for
decision
making.
(13%)
The response
provides at
least three
current,
evidencebased
resources
from the
literature that
appropriately
support the
assessment
and diagnosis
of the patient
in the
assigned case
study.
(11%)
Three
evidence-based
resources are
provided to
support
assessment
and diagnosis
of the patient
in the assigned
case study, but
they may only
provide vague
or weak
justification.
Two or fewer
resources are
provided to
support
assessment
and diagnosis
decisions. The
resources may
not be current
or evidence
based.
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Excellent
Good
Fair
Poor
Written Expression
and Formatting—
Paragraph
development and
organization:
Paragraphs make
clear points that
support welldeveloped ideas, flow
logically, and
demonstrate
continuity of ideas.
Sentences are
carefully focused—
neither long and
rambling nor short
and lacking
substance. A clear
and comprehensive
purpose statement
and introduction are
provided that
delineate all required
criteria.
5 (5%) - 5 (5%)
4 (4%) - 4 (4%)
3.5 (3.5%) - 3.5
0 (0%) - 3 (3%)
Paragraphs
and sentences
follow writing
standards for
flow,
continuity, and
clarity.
Paragraphs
and sentences
follow writing
standards for
flow,
continuity, and
clarity 80% of
the time.
Written Expression
and Formatting—
English writing
standards:
Correct grammar,
mechanics, and
punctuation
5 (5%) - 5 (5%)
4 (4%) - 4 (4%)
3 (3%) - 3 (3%)
0 (0%) - 2 (2%)
Uses correct
grammar,
spelling, and
punctuation
with no errors
Contains a few
(one or two)
grammar,
spelling, and
punctuation
errors
Contains
several (three
or four)
grammar,
spelling, and
punctuation
errors
Contains many
(≥ five)
grammar,
spelling, and
punctuation
errors that
interfere with
the reader’s
understanding
A clear and
comprehensive
purpose
statement,
introduction,
and conclusion
are provided
that delineate
all required
criteria.
Purpose,
introduction,
and
conclusion of
the
assignment
are stated, yet
they are brief
and not
descriptive.
(3.5%)
Paragraphs
and sentences
follow writing
standards for
flow,
continuity, and
clarity 60%–
79% of the
time.
Purpose,
introduction,
and conclusion
of the
assignment is
vague or off
topic.
Paragraphs
and sentences
follow writing
standards for
flow,
continuity, and
clarity less
than 60% of
the time.
No purpose
statement,
introduction,
or conclusion
were provided.
Total Points: 100
Name: NRNP_6635_Week4_Assignment_Rubric
EXIT
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4/4
Walden University
NRNP 6635: Psychopathology and Diagnostic Reasoning
Photo Credit: New Africa / Adobe Stock
Week 4: Anxiety Disorders, PTSD, and OCD
Your own experiences might tell you that expectations from family, friends, and work—as well as your
own expectations regarding achievement, success, and happiness—can create stress. Stressors are
a normal part of life, and stress traditionally has been viewed as an adaptive function with a set of
physiological responses to a stressor. In a situation where stress is perceived, the organism is
physiologically prepared to attack or flee from the threat. Those with effective fight or flight responses
tended to survive long enough to reproduce, so we are descended from those who are genetically
hardwired for self-protection. When you experience stress, your biology, emotions, social support,
motivation, environment, attitude, immune function, and wellness all feel the ripple effect.
This stress response is an adaptive response the human body has to threats; however, stress can
also be difficult to handle and—depending upon the nature and intensity of the stress—can result in
anxiety disorders, obsessive-compulsive disorders, or trauma- and stressor-related disorders. This
week, you will focus on these disorders and explore strategies to accurately assess and diagnose
them.
Learning Objectives
Students will:
Apply concepts, theories, and principles related to patient interviewing, diagnostic reasoning, and
recording patient information
Formulate differential diagnoses using DSM-5 criteria for patients with anxiety disorders, PTSD,
and OCD across the lifespan
Learning Resources
Required Readings (click to expand/reduce)
American Psychiatric Association. (2013). Anxiety disorders. In Diagnostic and statistical manual
of mental disorders (5th ed.). Arlington, VA: Author.
doi:10.1176/appi.books.9780890425596.dsm05
American Psychiatric Association. (2013). Obsessive compulsive and related disorders. In
Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
doi:10.1176/appi.books.9780890425596.dsm06
American Psychiatric Association. (2013). Trauma- and stressor-related disorders. In Diagnostic
and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
doi:10.1176/appi.books.9780890425596.dsm07
Sadock, B. J., Sadock, V. A., and Ruiz, P. (2015). Kaplan & Sadock’s synopsis of
psychiatry (11th ed.). Wolters Kluwer.
Chapter 9, Anxiety Disorders
Chapter 10, Obsessive-Compulsive and Related Disorders
Chapter 11, Trauma- and Stressor-Related Disorders
Chapter 31.11 Trauma-Stressor Related Disorders in Children
Chapter 31.13 Anxiety Disorders in Infancy, Childhood, and Adolescence
Chapter 31.14 Obsessive-Compulsive Disorder in Childhood and Adolescence
Document: Comprehensive Psychiatric Evaluation Template
Document: Comprehensive Psychiatric Evaluation Exemplar
Required Media (click to expand/reduce)
Classroom Productions. (Producer). (2015). Anxiety disorders [Video]. Walden University.
Classroom Productions. (Producer). (2012). The neurobiology of anxiety [Video]. Walden
University.
Classroom Productions. (Producer). (2015). Obsessive-compulsive disorders [Video]. Walden
University.
Classroom Productions. (Producer). (2015). Trauma, PTSD, and Trauma-Informed Care [Video].
Walden University.
MedEasy. (2017). Anxiety, OCD, PTSD and related psychiatric disorders | USMLE &
COMLEX [Video]. YouTube. https://www.youtube.com/watch?v=-BwzQF9DTlY
Video Case Selections for Assignment (click to expand/reduce)
Select one of the following videos to use for your Assignment this week. Then, access the document
“Case History Reports” and review the additional data about the patient in the specific video number
you selected.
Symptom Media. (Producer). (2017). Training title 15 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-15
Symptom Media. (Producer). (2016). Training title 21 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-21
Symptom Media. (Producer). (2016). Training title 37 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-37
Symptom Media. (Producer). (2016). Training title 40 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-40
Symptom Media. (Producer). (2017). Training title 55 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-55
Symptom Media. (Producer). (2017). Training title 85 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-85
Symptom Media. (Producer). (2018). Training title 95 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-95
Document: Case History Reports
Assignment: Assessing and Diagnosing
Patients With Anxiety Disorders, PTSD, and
OCD
“Fear,” according to the DSM-5, “is the emotional response to real or perceived imminent threat,
whereas anxiety is anticipation of future threat” (APA, 2013). All anxiety disorders contain some
degree of fear or anxiety symptoms (often in combination with avoidant behaviors), although their
causes and severity differ. Trauma-related disorders may also, but not necessarily, contain fear
and anxiety symptoms, but their primary distinguishing criterion is exposure to a traumatic event.
Trauma can occur at any point in life. It might not surprise you to discover that traumatic events are
likely to have a greater effect on children than on adults. Early-life traumatic experiences, such as
childhood sexual abuse, may influence the physiology of the developing brain. Later in life, there is
a chronic hyperarousal of the stress response, making the individual vulnerable to further stress
and stress-related disease.
Photo Credit: Hill Street Studios / Blend Images / Getty Images
For this Assignment, you practice assessing and diagnosing patients with anxiety disorders, PTSD,
and OCD. Review the DSM-5 criteria for the disorders within these classifications before you get
started, as you will be asked to justify your differential diagnosis with DSM-5 criteria.
To Prepare:
Review this week’s Learning Resources and consider the insights they provide about assessing
and diagnosing anxiety, obsessive-compulsive, and trauma- and stressor-related disorders.
Download the Comprehensive Psychiatric Evaluation Template, which you will use to complete this
Assignment. Also review the Comprehensive Psychiatric Evaluation Exemplar to see an example of
a completed evaluation document.
By Day 1 of this week, select a specific video case study to use for this Assignment from the Video
Case Selections choices in the Learning Resources. View your assigned video case and review the
additional data for the case in the “Case History Reports” document, keeping the requirements of
the evaluation template in mind.
Consider what history would be necessary to collect from this patient.
Consider what interview questions you would need to ask this patient.
Identify at least three possible differential diagnoses for the patient.
By Day 7 of Week 4
Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis
and critical-thinking process to formulate primary diagnosis.
Incorporate the following into your responses in the template:
Subjective: What details did the patient provide regarding their chief complaint and symptomology
to derive your differential diagnosis? What is 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 with supporting evidence, listed in
order from highest priority to lowest 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.
Reflection notes: What would you do differently with this client if you could conduct the session
over? 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.).
Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:
Please save your Assignment using the naming convention “WK4Assgn+last name+first initial.
(extension)” as the name.
Click the Week 4 Assignment Rubric to review the Grading Criteria for the Assignment.
Click the Week 4 Assignment link. You will also be able to “View Rubric” for grading criteria from
this area.
Next, from the Attach File area, click on the Browse My Computer button. Find the document you
saved as “WK4Assgn+last name+first initial.(extension)” and click Open.
If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my
paper(s) to the Global Reference Database.
Click on the Submit button to complete your submission.
Grading Criteria
To access your rubric:
Week 4 Assignment Rubric
Check Your Assignment Draft for Authenticity
To check your Assignment draft for authenticity:
Submit your Week 4 Assignment draft and review the originality report.
Submit Your Assignment by Day 7 of Week 4
To participate in this Assignment:
Week 4 Assignment
What’s Coming Up in Week 5?
Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
Next week, you will continue to practice your assessment and diagnosis skills, focusing on
disruptive, impulse-control, conduct, dissociative, and somatic symptom-related disorders.
Midterm Exam
You should also begin studying for your midterm exam, which is completed in Week 6. This will be
a 100-question, multiple-choice exam covering all topics in Week 1–Week 6 of the course. The
exams in your MSN program are designed to test your knowledge in preparation for your
certification exam and to simulate the certification exam environment. Accordingly, no outside
resources, including books, notes, websites, or any other type of resource, may be used to help
you complete the exams in your courses.
Photo Credit: [Vergeles_Andrey]/[iStock / Getty Images Plus]/Getty Images
Next Week
To go to the next week:
Week 5
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
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
Subjective:
CC (chief complaint):
HPI:
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:
ROS:
•
•
•
•
•
•
•
•
•
•
•
•
GENERAL:
HEENT:
SKIN:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
GENITOURINARY:
NEUROLOGICAL:
MUSCULOSKELETAL:
HEMATOLOGIC:
LYMPHATICS:
ENDOCRINOLOGIC:
Objective:
Physical exam: if applicable
© 2021 Walden University
Page 2 of 3
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
Diagnostic results:
Assessment:
Mental Status Examination:
Differential Diagnoses:
Reflections:
References
© 2021 Walden University
Page 3 of 3
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar
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 assignment in Weeks 4–10. After reviewing the
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: Discuss what you learned and what you might do
differently. Also include in your reflection a discussion related to legal/ethical
© 2021 Walden University
Page 1 of 6
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar
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 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 presents for psychiatric evaluation for anxiety. He is
currently prescribed sertraline which he finds ineffective. His PCP referred him for
evaluation and treatment.
Or
P.H., a 16-year-old Hispanic female, presents for psychiatric evaluation for
concentration difficulty. She is not currently prescribed psychotropic medications. She is
referred by her therapist for medication 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. First what is bringing the patient to your
evaluation. Then, include a PSYCHIATRIC REVIEW OF SYMPTOMS. The symptoms
onset, duration, frequency, severity, and 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.
Past Psychiatric History: This section documents the patient’s past treatments. Use
the mnemonic Go Cha MP.
© 2021 Walden University
Page 2 of 6
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar
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. Thirdly, 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.
Social 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?
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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
ROS: Cover all body systems that may help you include or rule out a differential
diagnosis. Please note: THIS IS DIFFERENT from a physical examination!
You should list each system as follows: General: Head: EENT: etc. You should list
these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears,
Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No
palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain
or blood.
GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or
tingling in the extremities. No change in bowel or bladder control.
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MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or
polydipsia.
Physical exam (If applicable and if you have opportunity to perform—document if
exam is completed by PCP): From head to toe, include what you see, hear, and feel
when doing your physical exam. You only need to examine the systems that are
pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must
describe what you see. Always document in head-to-toe format i.e., General: Head:
EENT: etc.
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, pseudohallucinations, 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-year-old 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. You will use supporting evidence from the literature to support your
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rationale. 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!), 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.).
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.
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