Comprehensive Psychiatric Evaluation Note and Patient Case Presentation
Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. 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 in a group setting during the last 4 weeks, 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 clinical practice guidelines.
Select a group patient for whom you conducted psychotherapy for a mood disorder during the last 4 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 psychiatric 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.
CASE STUDY: SY is a 16 years old Asian American female, seen along with her parents via telehealth for psychotherapy session. Patient presenting with history of depression, anxiety, and history of self harm. SY reports having a hard time since age 12 with SI first reported at age 14. Patient mother reports declining grades in school. SY reports depressive symptoms of sadness, hopelessness, feeling of excessive guilt, and thought of death. Patient also reports anxiety symptoms of irritability, uncontrollably worry. Patient also reports symptoms consistent with a trauma and stressor-related disorder due to nightmares, flashbacks, and intrusive thought related to past physical abuse by father. Therapist stated to SY parents that recent anger outbursts seem best explained by mood and traumatic stress rather than ODD since no prior history of oppositional behavior was reported. SY would benefit from outpatient treatment to reduce and manage her symptoms. A psychiatric evaluation is also recommended. SY and family will be followed up weekly for 8 weeks
Requirements: 4 pages
Please, follow the posted instructions carefully. This assignment will come with an introduction and conclusion page, with 5 most recent APA 7 edition references from 2017.
Please, pay attention to these, to be included in the paper:
Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What was the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective: What observations did you make during the psychiatric assessment?
Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.
Plan: What was your plan for psychotherapy (including one health promotion activity and one patient education strategy)? What was your plan for treatment and management, including alternative therapies? Include nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
Reflection notes: What would you do differently with this patient if you could conduct the session again?
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