NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar

Instructions for Using the Exemplar and Template – Please Read Carefully

If you encounter difficulties with the format or need guidance on what to include, refer to the Comprehensive Psychiatric Evaluation Template and the Rubric. It’s also advisable to thoroughly review the rubric to ensure you don’t lose points unnecessarily due to missed requirements. The following highlights, categorized by subject, are directly excerpted from the grading rubric for Weeks 4–10 assignments. After a comprehensive review of the rubric’s specifics, you can employ it as a reference for your NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation.

Subjective Section

– Chief complaint
– History of present illness (HPI)
– Past psychiatric history
– Medication trials and current medications
– Psychotherapy or previous psychiatric diagnosis
– Relevant substance use, family psychiatric/substance use, social, and medical history
– Allergies
– Review rating descriptions for grading standards

Objective Section

– Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
– Diagnostic results, including labs, imaging, or other assessments necessary for differential diagnoses
– Review rating descriptions for grading standards

Assessment Section

– Results of the mental status examination, presented in paragraph form
– At least three differentials with supporting evidence, listed from top priority to least priority
– Comparison of DSM-5-TR diagnostic criteria for each differential diagnosis and explanation of how DSM-5-TR criteria exclude other differentials to arrive at an accurate diagnosis
– Explanation of the critical-thinking process leading to the primary diagnosis
– Inclusion of pertinent positives and pertinent negatives for the specific patient case
– Reflection on the case, discussing what was learned and what could be done differently
– Discussion of legal/ethical considerations (beyond confidentiality and consent for treatment), social determinants of health, health promotion, disease prevention, patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background)

Comprehensive Evaluation Note Explanation

The comprehensive evaluation is typically the initial assessment for new patients. This note focuses on ruling out other mental illnesses to demonstrate a thorough assessment. Symptoms present and absent from various illnesses should be documented to show a comprehensive evaluation.

Exemplar Begins Here

Chief Complaint (CC): A concise statement indicating why the patient seeks assessment. This statement should be verbatim from the patient’s own description of why they are seeking evaluation. For patients with cognitive deficits, this statement can be obtained from a family member.

History of Present Illness (HPI): This section starts with the 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 presenting 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.”

This section continues with a detailed symptom analysis, which is crucial for patient care, coding, and billing analysis. It paints a comprehensive picture of the patient’s condition, starting with why the patient is seeking evaluation. Include a PSYCHIATRIC REVIEW OF SYMPTOMS, detailing symptom onset, duration, frequency, severity, and impact. This description guides the formulation of differential diagnoses, seeking symptoms aligning with DSM-5-TR diagnoses that correspond to mental health and substance use disorders.

Past Psychiatric History: Document the patient’s past treatments, using the mnemonic “Go Cha MP”:

– General Statement: Typically, the patient’s first treatment experience (e.g., “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: List if applicable.
– Hospitalizations: Indicate the number of hospitalizations, their dates and locations, detox and residential treatment history, and any history of suicidal, homicidal, or self-harm behaviors.
– Medication Trials: Document previous psychotropic medications, the patient’s reactions (effective, not effective, adverse reaction), and include examples (e.g., “Haloperidol [dystonic reaction], risperidone [hyperprolactinemia], olanzapine [effective, insurance wouldn’t pay for it]”).
– Psychotherapy or Previous Psychiatric Diagnosis: You can capture the type of psychotherapy the patient knows, whether it was helpful, and why. Alternatively, document previous diagnoses from prior treatments and providers. You may also choose to include both.

Substance Use History: This section covers the patient’s history of caffeine, nicotine, illicit substances (including marijuana), and alcohol use. Include daily usage amounts, the last known use, and specify the method of use (e.g., inhales, snorts, IV). Additionally, document any histories of withdrawal complications such as tremors, Delirium Tremens, or seizures.

Family Psychiatric/Substance Use History: Document any family history of psychiatric illness, substance use disorders, and family suicides. You may use a genogram to visually depict this information and provide a reader’s key or describe it in narrative form.

Social History: The length of this section may vary depending on whether the evaluation is for psychotherapy or psychopharmacology. At a minimum, include:

– Place of birth and upbringing
– Number of siblings and the patient’s birth order
– Current living arrangements, marital status, and the number of children
– Educational level
– Hobbies
– Work history (current profession, disabled, unemployed, retired)
– Legal history (past and current issues)
– Trauma history (childhood or adult)
– Violence history (personal, home, community, sexual)
– Medical History: This section contains information about illnesses, surgeries, and any history of seizures or head injuries.

Current Medications: Include details on medication dosage, frequency, duration of use, and the reason for use. Also, document over-the-counter (OTC) or homeopathic products used.

Allergies: Document medication, food, and environmental allergies separately, providing a description of the allergic reaction (e.g., angioedema, anaphylaxis) to distinguish true reactions from intolerances.

Reproductive History: Include menstrual history (date of last menstrual period), pregnancy status, lactation status, contraceptive use, and details about sexual activities, such as oral, anal, vaginal, or other, as well as any sexual concerns.

Review of Systems (ROS): This section covers all body systems relevant for including or ruling out a differential diagnosis. Note that this is different from a physical examination. Each system should be listed in bullet format and documented in order from head to toe (e.g., General: Head: EENT:). Provide an example for each system to describe whether there are relevant issues.

NURS-6630N Week 3: Self Assessment Quiz 100% correct with rationale

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: No burning on urination, urgency, hesitancy, odor, or unusual color.
– NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
– MUSCULOSKELETAL: No muscle pain, 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 performed): Document findings from head to toe, including visual, auditory, and tactile observations. Examine only the systems pertinent to the chief complaint, HPI, and history. Describe findings in detail and avoid using terms like “WNL” or “normal.”

Diagnostic Results: Include any relevant laboratory results, X-rays, or other diagnostics required for differential diagnoses. Support your assessments with evidence and guidelines.

Assessment

Mental Status Examination:

In this section, present the mental status examination (MSE) in paragraph form, without using a checklist. Describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.), cognition, insight, judgment, and any suicidal or homicidal ideation. Customize this section to reflect your patient’s specific MSE, avoiding copying from an example.

Differential Diagnoses:

Provide at least three differential diagnoses supported by evidence. Explain how each differential diagnosis is either ruled in or ruled out, and justify your primary diagnostic impression. Utilize literature to support your rationale, including pertinent positives and pertinent negatives specific to the patient’s case.

Reflection:

Reflect on the case and discuss whether you agree with your preceptor’s assessment and diagnostic impression. Explain why or why not and mention what you’ve learned from the case and what you would do differently. Additionally, engage in a discussion concerning legal and ethical considerations (beyond confidentiality and consent), social determinants of health, health promotion, disease prevention, and how these factors relate to patient characteristics, PMH, and other risk factors.

References (begin on the next page):

Include a minimum of three evidence-based, peer-reviewed journal articles or evidence-based guidelines relevant to the case to support your diagnostics and differential diagnoses. Format your references according to APA 7th edition guidelines.