Comprehensive Psychiatric Evaluation Note and Patient Case Presentation
Assignment 2: 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.
Psychotherapy for a mood disorder
In the case of psychotherapy for a mood disorder, the focus of the psychiatric evaluation would be on assessing the patient’s symptoms and experiences related to their mood disorder, such as depression or bipolar disorder. This would involve gathering information from the patient through an interview, as well as observing the patient during the evaluation.
The mental status examination would include assessing the patient’s mood, affect, thought process, thought content, perception, cognition, insight, and judgment. Based on the patient’s reported symptoms and observed behavior, the clinician would consider various differential diagnoses and prioritize them based on their likelihood. The clinician would then make a primary diagnosis, which would be supported by the patient’s symptoms and align with the DSM-5 diagnostic criteria.
The psychotherapeutic plan for treating a mood disorder would typically involve some form of talk therapy, such as cognitive-behavioral therapy (CBT) or interpersonal therapy (IPT). Medications may also be prescribed, depending on the severity of the disorder. The plan may also include health promotion activities such as regular exercise, healthy eating, and sleep hygiene, as well as patient education strategies to help the patient better understand their disorder and how to manage it. Progress would be monitored and goals would be reviewed regularly.
It is important to note that the specifics of the psychiatric evaluation and treatment plan will vary depending on the specific patient and the specific mood disorder they are experiencing.
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.
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.
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 differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.
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?
The Assignment is asking you to 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. This includes recording a video presentation of the case, in which you dress professionally and present yourself in a professional manner, displaying your photo ID at the start of the video when you introduce yourself, and not including any information that violates the principles of HIPAA.
In the presentation, you should include subjective and objective data, assessment from most recent mental status exam, current psychiatric diagnosis including differentials that were ruled out, current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided), and patient progress toward treatment goals. You should also include at least five scholarly resources to support your assessment and diagnostic reasoning.