Comprehensive Psychiatric Evaluation Note and Patient Case Presentation

Comprehensive Psychiatric Evaluation Note and Patient Case Presentation

Comprehensive Psychiatric Evaluation Note and Patient Case Presentation
Comprehensive Psychiatric Evaluation Note and Patient Case Presentation

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

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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