NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
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:
Physical exam: if applicable
Diagnostic results:
Assessment
Mental Status Examination:
Differential Diagnoses:
Reflections:
PRECEPTOR VERFICIATION:
I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.
Preceptor signature: ________________________________________________________
Date: ________________________
References
© 2022 Walden University Page 1 of 3
Please do the written part.
Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video.
In your presentation:
· Dress professionally and present yourself in a professional manner.
· Display your photo ID at the start of the video when you introduce yourself.
· Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
· Present the full case. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis including differentials that were ruled out.
· Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
Be succinct in your presentation, and do not exceed 8 minutes. Address the following:
· Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?
· Objective: What observations did you make during the interview and review of systems?
· Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis and why?
· 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.
· PRAC_6635_Week7_Assignment2_Part1__Rubric
PRAC_6635_Week7_Assignment2_Part1__Rubric
Criteria
Ratings
Pts
This criterion is linked to a Learning OutcomePhoto ID display and professional attire
5 to >0.0 pts
Excellent
Photo ID is displayed. The student is dressed professionally.
0 pts
Fair
0 pts
Good
0 pts
Poor
Photo ID is not displayed. Student must remedy this before grade is posted. The student is not dressed professionally.
5 pts
This criterion is linked to a Learning OutcomeTime
5 to >0.0 pts
Excellent
The video does not exceed the 8-minute time limit.
0 pts
Fair
0 pts
Good
0 pts
Poor
The video exceeds the 8-minute time limit. (Note: Information presented after the 8 minutes will not be evaluated for grade inclusion.)
5 pts
This criterion is linked to a Learning OutcomeDescription of chief complaint and history of present illness
5 to >4.0 pts
Excellent
The student provides an accurate, clear, and complete description of the chief complaint and history of present illness.
4 to >3.0 pts
Good
The student provides an accurate description of the chief complaint and history of present illness.
3 to >1.0 pts
Fair
The student provides a vague, inaccurate, or incomplete description of the chief complaint and history of present illness, or description is missing.
1 to >0 pts
Poor
The student provides a completely inaccurate, or incomplete description of the chief complaint and history of present illness, or the description is missing.
5 pts
This criterion is linked to a Learning OutcomeDescription of past psychiatric, substance use, medical, social, and family history
5 to >4.0 pts
Excellent
The student provides an accurate, clear, and complete description of past psychiatric, substance use, medical, social, and family history.
4 to >3.0 pts
Good
The student provides an accurate description of past psychiatric, substance use, medical, social, and family history.
3 to >1.0 pts
Fair
The student provides a vague, inaccurate, or incomplete description of psychiatric, substance use, medical, social, and family history, or description is missing.
1 to >0 pts
Poor
The student provides a completely inaccurate, or incomplete description of psychiatric, substance use, medical, social, and family history, or description is missing.
5 pts
This criterion is linked to a Learning OutcomeDiscussion of most recent mental status exam and observations made during interview and review of systems
15 to >13.0 pts
Excellent
The student provides an accurate, clear, and complete discussion of results from most recent mental status exam and observations made during interview and review of systems.
13 to >11.0 pts
Good
The student provides an accurate discussion of results from most recent mental status exam and observations made during interview and review of systems.
11 to >10.0 pts
Fair
The student provides a vague, inaccurate, or incomplete discussion of results from most recent mental status exam and observations made during interview and review of systems.
10 to >0 pts
Poor
All or most of the discussion is inaccurate or missing.
15 pts
This criterion is linked to a Learning OutcomeDiscussion of diagnostics with results
10 to >8.0 pts
Excellent
The student provides an accurate, clear, and complete discussion of diagnostics with results.
8 to >7.0 pts
Good
The student provides an accurate discussion of diagnostics with results.
7 to >6.0 pts
Fair
The student provides a vague, inaccurate, or incomplete discussion of diagnostics with results.
6 to >0 pts
Poor
All or most of the discussion is inaccurate or missing.
10 pts
This criterion is linked to a Learning OutcomeDiagnostic Impression with three (3) differential diagnosesReflection on this case
25 to >22.0 pts
Excellent
The student provides an accurate, clear, and complete diagnostic impression with three (3) differentials. … Reflections are thorough, thoughtful, and demonstrate critical thinking. …Reflections contain all 3 elements from the assignment directions.
22 to >19.0 pts
Good
The student provides an accurate diagnostic impression with three (3) differentials…. Reflections demonstrate critical thinking…. Reflections contain 2 of the elements from the assignment directions.
19 to >17.0 pts
Fair
The student provides a vague, inaccurate, less than 3, or incomplete diagnostic impression with differentials…. Reflections are somewhat general or do not demonstrate critical thinking…. Reflections contain 1 of the required elements from the assignment directions.
17 to >0 pts
Poor
All or most of the discussion is inaccurate or missing. No diagnostic impression and less than 2 differential diagnoses…. Reflections are incomplete, inaccurate, or missing. … There are no Reflections elements from the assignment directions.
25 pts
This criterion is linked to a Learning OutcomePresentation style
5 to >4.0 pts
Excellent
Presentation style is exceptionally clear, professional, and focused.
4 to >3.0 pts
Good
Presentation style is clear, professional, and focused.
3 to >2.0 pts
Fair
Presentation style is mostly clear, professional, and focused
2 to >0 pts
Poor
Presentation style is unclear, unprofessional, and/or unfocused.
5 pts
Total Points: 75
**Comprehensive Psychiatric Evaluation**
—
**Chief Complaint (CC):**
The patient presents with a chief complaint of persistent feelings of sadness, low energy, and difficulty concentrating.
**History of Present Illness (HPI):**
The patient reports experiencing symptoms of depression for the past six months. These symptoms include pervasive sadness, decreased interest in activities, fatigue, and difficulty concentrating. The patient notes that these symptoms have significantly impacted their ability to function at work and in social situations. Additionally, the patient reports occasional thoughts of hopelessness and worthlessness but denies any active suicidal ideation or intent.
**Past Psychiatric History:**
– General Statement: The patient has a history of depression, which was first diagnosed five years ago.
– Caregivers: None reported.
– Hospitalizations: The patient was hospitalized once three years ago for a major depressive episode.
– Medication Trials: The patient has previously been treated with sertraline and escitalopram, both of which provided partial relief of symptoms but were discontinued due to side effects.
– Psychotherapy or Previous Psychiatric Diagnosis: The patient has engaged in individual psychotherapy intermittently over the past five years.
**Substance Current Use and History:**
The patient denies any current substance use. Past history includes occasional alcohol use but no significant substance abuse.
**Family Psychiatric/Substance Use History:**
There is a family history of depression on the patient’s maternal side. The patient’s mother has a history of depression and anxiety.
**Psychosocial History:**
The patient is employed full-time in a demanding job. They report some stressors related to work but otherwise have a stable living situation and supportive social network.
**Medical History:**
– Current Medications: None reported.
– Allergies: No known drug allergies.
– Reproductive Hx: Not applicable.
**Review of Systems (ROS):**
– GENERAL: Reports fatigue and decreased energy level.
– HEENT: No complaints.
– SKIN: No complaints.
– CARDIOVASCULAR: No complaints.
– RESPIRATORY: No complaints.
– GASTROINTESTINAL: No complaints.
– GENITOURINARY: No complaints.
– NEUROLOGICAL: Reports difficulty concentrating.
– MUSCULOSKELETAL: No complaints.
– HEMATOLOGIC: No complaints.
– LYMPHATICS: No complaints.
– ENDOCRINOLOGIC: No complaints.
**Diagnostic Results:**
– CBC: Within normal limits.
– CMP: Within normal limits.
– Thyroid function tests: Within normal limits.
**Assessment:**
**Mental Status Examination (MSE):**
The patient presents with a depressed mood, psychomotor retardation, and impaired concentration. There is no evidence of psychosis or suicidal ideation. Insight and judgment appear intact.
**Differential Diagnoses:**
Major Depressive Disorder (MDD)
Persistent Depressive Disorder (PDD)
Adjustment Disorder with Depressed Mood
**Primary Diagnosis:**
Major Depressive Disorder (MDD) is the primary diagnosis due to the presence of persistent depressive symptoms lasting more than two weeks, significant impairment in functioning, and previous history of depression.
**Reflections:**
In a similar patient evaluation, I would ensure to explore potential contributing factors to the patient’s depressive symptoms, such as recent life stressors or changes in medication. Additionally, I would consider involving the patient’s family or support system in the treatment plan to provide additional support.
**Social Determinant of Health (HealthyPeople 2030):**
One social determinant of health relevant to this case is socioeconomic status (SES). Lower SES is associated with increased risk of depression due to limited access to resources, including healthcare and social support.
**Health Promotion Activity and Patient Education:**
A health promotion activity for this patient could involve engaging in regular physical activity, which has been shown to improve mood and overall well-being. Patient education should focus on stress management techniques and building coping skills to better manage depressive symptoms.
—
**Preceptor Verification**
Preceptor signature: ________________________________________________________
Date: ________________________
—
This written evaluation provides a detailed overview of the patient’s psychiatric history, current symptoms, assessment findings, and differential diagnoses, adhering to the guidelines provided.
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