Comprehensive psychiatric evaluations are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive 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 during the last 5 weeks, using the Comprehensive Psychiatric Evaluation Template provided. You will then use this note to develop and record a case presentation for this patient.
RESOURCES
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HSoft Corporation. (2020). Meditrek: HomeLinks to an external site.. https://edu.meditrek.com/Default.html
Note: Use this website to log into Meditrek to report your clinical hours and patient encounters.
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Document: Comprehensive Psychiatric Evaluation Template Download Comprehensive Psychiatric Evaluation Template(Word document)
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Document: Comprehensive Psychiatric Evaluation Exemplar Download Comprehensive Psychiatric Evaluation Exemplar(Word document)
Recommended Resources
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American Psychiatric Association. (2022). Disruptive, impulse-control, and conduct disordersLinks to an external site.. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.).
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American Psychiatric Association. (2022). Dissociative disordersLinks to an external site.. Diagnostic and statistical manual of mental disorders (5th ed., text rev.).
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American Psychiatric Association. (2022). Somatic symptom and related disordersLinks to an external site.. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.).
- Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.
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Walden University. (2020). College of Nursing practicum manual: Master of science in nursing (MSN) and post-master’s certificate programsLinks to an external site.. https://academicguides.waldenu.edu/fieldexperience/son/formsanddocuments
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Walden University Field Experience. (2020a). Field experience: College of NursingLinks to an external site.. https://academicguides.waldenu.edu/fieldexperience/son/home
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Walden University Field Experience. (2020b). Student practicum resources: NP student orientationLinks to an external site.. https://academicguides.waldenu.edu/StudentPracticum/NP_StudentOrientation
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American Psychiatric Association. (2022). Anxiety disorders. In Diagnostic and statistical manual of mental disordersLinks to an external site. (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x05_Anxiety_Disorders
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American Psychiatric Association. (2022). Obsessive compulsive and related disorders In Diagnostic and statistical manual of mental disordersLinks to an external site. (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x06_Obsessive_Compulsive_and_Related_Disorders
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American Psychiatric Association. (2022). Trauma- and stressor-related disorders.. In Diagnostic and statistical manual of mental disordersLinks to an external site. (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x07_Trauma_and_Stressor_Related_Disorders
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Boland, R. & Verduin, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.
- Chapter 8, “Anxiety Disorders”
- Chapter 9, “Obsessive-Compulsive and Related Disorders”
- Chapter 10, “Trauma- and Stressor-Related Disorders”
- Chapter 2- only sections 2.13, “Anxiety Disorders of Infancy, Childhood, and Adolescence: Separation Anxiety Disorder, Generalized Anxiety Disorder, and Social Anxiety Disorder (Social Phobia)”; 2.14 “Selective Mutism” and 2.15 “Obsessive-Compulsive Disorder in Children and Adolescence”
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
TO PREPARE
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Select a patient that you examined during the last 5 weeks. Review prior resources on the disorder this patient has.
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In Week 5: Assignment 2, Part 1, you submitted the Video Evaluation Presentation.
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In Week 5: Assignment 2, Part 2, you will submit the documentation.
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Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided in the Learning Resources. There is also a completed exemplar document in the Learning Resources so that you can see an example of the types of information a completed evaluation document should contain. All psychiatric evaluations must be signed, and each page must be initialed by your Preceptor. You will submit your document in Week 5 Assignment, Part 2 area and you will include the complete Comprehensive Psychiatric Evaluation as a Word document, as well as a PDF/images of each page that is initialed and signed by your Preceptor. You must submit your document using Turn It In. Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.
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Develop a video case presentation, based on your progress note of this patient, that includes chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis, including differentials that were ruled out.
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Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.
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Ensure that you have the appropriate lighting and equipment to record the presentation.
ASSIGNMENT
Record yourself presenting the complex case for your clinical patient.
Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video.
In your presentation:
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Dress professionally and present yourself in a professional manner.
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Display your photo ID at the start of the video when you introduce yourself.
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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).
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Present the full case. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis, including differentials that were ruled out.
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Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
Be succinct in your presentation, and do not exceed 8 minutes. Address the following:
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Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?
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Objective: What observations did you make during the interview and review of systems?
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Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why?
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Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
BY DAY 7
Submit your Comprehensive Psychiatric Evaluation documentation, including a Word document and scanned PDF/images of each page that is initialed and signed by your Preceptor.
Note: In Week 5: Assignment 2, Part 1 you will submit the Video Evaluation Presentation.
SUBMISSION INFORMATION
Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.
- To submit your completed assignment, save your Assignment as WK5Assgn2_LastName_Firstinitial
- Then, click on Start Assignment near the top of the page.
- Next, click on Upload File and select Submit Assignment for review.
*For all assignments please submit to Turnitin.
*Please use the DSM for diagnostic criteria. Cite it in your paper and the reference list.
- Please review the grading rubric before submitting assignments and if required by the rubric, include a purpose statement, introduction, and conclusion, information on social determinants of health, health promotion, and disease prevention, and your references placed in APA format.
- For case presentations:
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The chief complaint is the patient’s own words placed in quotation marks. For example “I am depressed.” not the patient is here for depression.
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Add your video and the DSM to the reference list.
- For the HPI include the patient’s symptoms, the severity of symptoms, and the duration of symptoms.
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If no diagnostic test/tool/lab was performed, you will include why you are ordering each test/tool/lab and how it will help you rule in/out
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The MSE includes appearance, behavior, speech, mood, affect, thought content, thought process, judgment, cognition, and insight.
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Make sure all references are no more than 5 years old.
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Points will be deducted by the criteria in the rubric for each assignment.
Please let me know if you have any questions.
Patient Case Study:
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Patient reports no medical history. Patient’s chief complaint is “feeling anxious, depressed and irritable”. Patient reports feeling “guilty and mad all the time”. Patient is an educated, full time employee in the medical field. 40 year old female Reports being a breastfeeding mom of an 18 month old baby and two older children.. Reports irritability and mood swings, sometimes throws things at the wall. Patient reports sleeping less than 6 hours daily. Patient reports feeling “everyone always needs something from me and i feel overwhelmed,overstimulated, and like Ican’t keep up”. Patient screams and feels nervous a lot. Patient states there is so much to do and she worries a lot and feels rushed and under pressure. Both parent aresrill married. one sister living in maryland. Family negative for psychiatric history. Husband states patient has too think skin, too sensitive, too reactive, and takes everything too presonally. Patient states hard time falling asleep. No drug allergies, no medical history. Denies suicidal feelings. Modd is currently anxious and depressed. Congruent with patient affect on presentation. Patient reports not having sufficient help at home from spouse managing children. Patient reports getting angry and throwing things. Patient reports feeling “guilty” when leaving to take time for herself. Patient reports good appetite, healthy lifestyle, workouts daily at 4:45 am. All llabs normal except vitamin D level. Patient reports Patient started on 10mg paxil orally daily. Patient to follow up within 30 days. Patient states she feels anger towards husband. Patient recommended to seek therapy. Patient Primary diagnosis anxiety via DSM V.
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