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Posted: May 11th, 2022
NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation
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:
NRNP/PRAC 6645 Comprehensive
Psychiatric Evaluation
NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation –
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
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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 . NRNP/PRAC
6645 Comprehensive Psychiatric Evaluation
· 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.
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