For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member. This statement is verbatim of the patient’s own words about why presenting for assessment. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.) EXEMPLAR BEGINS HERE CC (chief complaint): A brief statement identifying why the patient is here. 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 illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. You will practice writing this type of note in this course. (The comprehensive evaluation is typically the initial new patient evaluation.
Also include in your reflection a discussion related to legal/ethical considerations ( demonstrate critical thinking beyond confidentiality and consent for treatment !), health promotion and © 2021 Walden University of 6 NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.). Include: Discuss what you learned and what you might do differently. Read rating descriptions to see the grading standards! Reflect on this case. Include pertinent positives and pertinent negatives for the specific patient case. Explain the critical-thinking process that led you to the primary diagnosis you selected. 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. List them from top priority to least priority.
At least three differentials with supporting evidence. Read rating descriptions to see the grading standards! In the Assessment section, provide: Results of the mental status examination, presented in paragraph form. 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.
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After reviewing the full details of the rubric, you can use it as a guide. Below highlights by category are taken directly from the grading rubric for the assignment in Weeks 4–10. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required.
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P3 NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar 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.
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