Comprehensive Psychiatric Evaluation: [Patient’s Initials or ID]

Here’s a structured template for the Comprehensive Psychiatric Evaluation assignment, which should help you in organizing your assessment. You can fill it out with specific details based on your case study.

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**NRNP/PRAC 6635 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**

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**Subjective:**

– **CC (chief complaint):** [Patient’s primary reason for seeking help]

– **HPI (History of Present Illness):** [Detailed description of the symptoms, including onset, duration, severity, and impact on daily functioning]

– **Past Psychiatric History:**
– **General Statement:** [Brief overview of past psychiatric issues and treatments]
– **Caregivers (if applicable):** [Information about caregivers and their role in the patient’s mental health]
– **Hospitalizations:** [Details of any psychiatric hospitalizations, including dates and reasons]
– **Medication trials:** [List of past and current psychiatric medications, including effectiveness and side effects]
– **Psychotherapy or Previous Psychiatric Diagnosis:** [Past psychotherapy experiences and previous diagnoses]

– **Substance Current Use and History:** [Details of current and past substance use, including frequency and amount]

– **Family Psychiatric/Substance Use History:** [Relevant information about family history of psychiatric disorders or substance use]

– **Psychosocial History:** [Patient’s social background, including education, occupation, relationships, and any social stressors]

– **Medical History:**
– **Current Medications:** [List of all current medications and dosages]
– **Allergies:** [Known allergies]
– **Reproductive Hx:** [Relevant reproductive health history, if applicable]

– **ROS (Review of Systems):**
– **GENERAL:** [General health, weight changes, fatigue]
– **HEENT:** [Head, eyes, ears, nose, throat]
– **SKIN:** [Skin changes, rashes]
– **CARDIOVASCULAR:** [Heart-related symptoms, blood pressure]
– **RESPIRATORY:** [Breathing issues, cough]
– **GASTROINTESTINAL:** [Digestive symptoms, appetite changes]
– **GENITOURINARY:** [Urinary symptoms, reproductive health]
– **NEUROLOGICAL:** [Headaches, seizures, memory issues]
– **MUSCULOSKELETAL:** [Muscle or joint pain, mobility issues]
– **HEMATOLOGIC:** [Blood disorders, bruising]
– **LYMPHATICS:** [Swollen lymph nodes]
– **ENDOCRINOLOGIC:** [Thyroid issues, hormone imbalances]

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**Objective:**

– **Physical exam:** [Findings from physical examination, if applicable]

– **Diagnostic results:** [Results from any diagnostic tests or imaging studies]

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**Assessment:**

– **Mental Status Examination:** [Detailed assessment of the patient’s mental status, including appearance, behavior, mood, affect, speech, thought processes, thought content, perception, cognition, and insight]

– **Differential Diagnoses:** [List of potential diagnoses to consider based on the patient’s presentation]

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**Reflections:** [Personal reflections on the case, including any challenges encountered, insights gained, and plans for further evaluation or treatment]

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**References** [Cite any sources used in the preparation of the evaluation]

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Feel free to adjust the template as needed to fit the specifics of your assignment and case study.

NRNP/PRAC 6635 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:

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

Diagnostic results:

Assessment:

Mental Status Examination:

Differential Diagnoses:

Reflections:

References

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