Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive psychiatric evaluation notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care 

Comprehensive Psychiatric Evaluation Note and Patient Case Presentation

Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive psychiatric evaluation notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will document information about a patient that you examined at your practicum site, using the Comprehensive Psychiatric Evaluation Note Template provided. You will then use this note to develop and record a case presentation for this patient. 

To Prepare

· Review this week’s Learning Resources and consider the insights they provide about impulse-control and conduct disorders. 

· Select a patient for whom you conducted psychotherapy for an impulse control or conduct disorder during the last 6 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide. All psychiatric evaluation notes must be signed, and each page must be initialed by your Preceptor. When you submit your note, you should include the complete comprehensive evaluation note as a Word document and pdf/images of each page that is initialed and signed by your Preceptor. You must submit your note using SafeAssign.
Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Grading Policy.

· Then, based on your evaluation of this patient, develop a video presentation of the case. Plan your presentation using the Assignment rubric and rehearse what you plan to say. Be sure to review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.

· Include at least five scholarly resources to support your assessment and diagnostic reasoning.

· Ensure that you have the appropriate lighting and equipment to record the presentation.

The Assignment

Record yourself presenting the complex case study for your clinical patient. In your

presentation: 

· Dress professionally with a lab coat 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 complex case study. Be succinct in your presentation, and do not exceed 8 minutes. Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including

Rubric Detail

Select Grid View or List View to change the rubric’s layout.

Content

Name: PRAC_6645_Week7_Assignment2_Rubric

  Excellent Good Fair Poor
Photo ID display and professional attire

Points:

Points Range:
5 (5%) – 5 (5%)

Photo ID is displayed. The student is dressed professionally.

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

Photo ID is not displayed. Student must remedy this before grade is posted. The student is not dressed professionally.

Feedback:

Time

Points:

Points Range:
5 (5%) – 5 (5%)

The video does not exceed the 8-minute time limit.

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

Feedback:

Points:

Points Range:
0 (0%) – 3 (3%)

The video exceeds the 8-minute time limit. (Note: Information presented after 8 minutes will not be evaluated for grade inclusion.)

Feedback:

Discuss Subjective data:
• Chief complaint
• History of present illness (HPI)
• Medications
• Psychotherapy or previous psychiatric diagnosis
• Pertinent histories and/or ROS

Points:

Points Range:
9 (9%) – 10 (10%)

The video accurately and concisely presents the patient’s subjective c

Chief Complaint: The patient stated, “I started hearing voices 2 weeks ago saying you are dead, you are dead”.

VITAL

Height: 5’11”

Weight: 174 lbs.

BP: 129/88

Temperature: 97.3

Pulse: 72

Respiratory rate: 18

O2 Saturation: 97%

Pain: Denied pain

Diagnoses: Schizophrenia

Allergies:

Patient has no known drug allergies

No food allergies recorded

No environmental allergies recorded

Medications

Quetiapine Fumarate (Seroquel) 100 mg by mouth 1 tablet daily at bedtime 

 

Smoking Status

Non-smoker 06/10/2020

 

GENDER IDENTITY

MALE

SEXUAL ORIENTATION

Straight or heterosexual

SOCIAL HISTORY

Works in a Grocery store as a Stalker. Lives with 2 siblings. Completed High school diploma.

ONGOING HEALTH PROBLEM

Not getting enough sleep

FAMILY HEALTH HISTORY: No Psychiatric problem verbalized

SOCIAL HISTORY

Works in a Grocery store as a Stalker. Lives with 2 siblings. Completed High school diploma.

DEVELOPMENTAL HISTORY

Grew up with both Parents. Denies physical and sexual abuse


SUBJECTIVE

The patient is a 44 years old African American male who was seen today in the facility with consent obtained, with diagnosis of Schizophrenia. He reports that he started hearing voices 2 weeks ago saying “he is dead, he is dead”. he was involved in a violent altercation with his neighbor that involved calling police but charges were not pressed. He voluntarily checked himself too the ER and was transferred to psychiatric hospital for weeks. He voiced that this is the first time he is hearing voices. Prior to the hospitalization he reports sleeping for about 2 – 3 hour a day.

               

OBJECTIVE

The patient is alert and oriented x 3, verbally responsive with intact memories. He denies suicidal/homicidal ideation, reports hearing voices telling him, “You are dead, you are dead”, he denies seeing things that are not present. Further evaluation of mental status reveals the following:

C-SSRS (LIFETIME)

1. WISH TO BE DEAD; no.

have you wished you were dead or wish you could go to sleep and not wake up?

2. NON-SPECIFIC ACTIVE SUICIDAL THOUGHTS: In the past, not now.

have you had any thoughts of killing yourself? No, but in the past

3. ACTIVE SUICIDAL IDEATIONS WITH ANY METHODS (NOT PLA

NRNP/PRAC 6645 Comprehensive Psychiatric

Evaluation Note Template

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 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 illn

NRNP/PRAC 6645 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:

(include psychiatric ROS rule out)

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:

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:

Differential Diagnoses:

Reflections:

Case Formulation and Treatment Plan:  

References

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