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. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignment in Weeks 4–10. After reviewing the full details of the rubric, you can use it as a guide.
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
- 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.
- Read rating descriptions to see the grading standards!
In the Assessment section, provide:
- Results of the mental status examination, presented in paragraph form.
- At least three differentials with supporting evidence. List them from top priority to least priority. 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. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
- Read rating descriptions to see the grading standards!
Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
(The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. 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. 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. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.
HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:
N.M. is a 34-year-old Asian male presents for psychiatric evaluation for anxiety. He is currently prescribed sertraline which he finds ineffective. His PCP referred him for evaluation and treatment.
P.H., a 16-year-old Hispanic female, presents for psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her therapist for medication evaluation and treatment.
Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.
Paint a picture of what is wrong with the patient. First what is bringing the patient to your evaluation. Then, include a PSYCHIATRIC REVIEW OF SYMPTOMS. The symptoms onset, duration, frequency, severity, and impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.
Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP.
General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13.
Caregivers are listed if applicable.
Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors?
Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it)
Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. Thirdly, you could document both.
Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.
Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information. Be sure to include a reader’s key to your genogram or write up in narrative form.
Social History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology. However, at a minimum, please include:
Where patient was born, who raised the patient
Number of brothers/sisters (what order is the patient within siblings)
Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children?
Work History: currently working/profession, disabled, unemployed, retired?
Legal history: past hx, any current issues?
Trauma history: Any childhood or adult history of trauma?
Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)
Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries.
Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.
Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns
ROS: Cover all body systems that may help you include or rule out a differential diagnosis. Please note: THIS IS DIFFERENT from a physical examination!
You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
Physical exam (If applicable and if you have opportunity to perform—document if exam is completed by PCP): From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e., General: Head: EENT: etc.
Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.
He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.
Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.
Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?
Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
References (move to begin on next page)
You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
Week 3: Assessing and Diagnosing a Patient with Post-Traumatic Stress Disorder (PTSD) Based on Training Title 18
College of Nursing-PMHNP, Walden University
NRNP 6635: Psychopathology and Diagnostic Reasoning
Assignment Due Date
Psychiatric evaluation is a diagnostic tool that enables the psychiatrist to evaluate clients’ behaviors, thought processes, and memories. This is a comprehensive evaluation of the patient A.D., a female army officer as a MOS 92M Mortuary Affairs Specialist. The patient recently served in Iraq, after which she started experiencing mental health problems like depression and guilt. His evaluation shall consider A.D.’s past psychiatric history, substance current use and history, family psychiatric/substance use history, psychosocial history, and differential diagnoses. This is a comprehensive psychiatric evaluation of the patient, A.D., a twenty-year-old, to diagnose her mental health problem.
CC (chief complaint): A.D. is a twenty-year-old female military officer present for post-traumatic stress disorder (PTSD). She is in therapy upon the recommendation of her boyfriend L, who she lives with off-base. She said that other people in her life think that she has PTSD due to her military service.
HPI: The client, A.D., is a twenty-year-old female army officer currently serving MOS 92M Mortuary Affairs Specialist, present for post-traumatic stress disorder (PTSD). She has been on anti-depressants throughout her childhood and teenage years but had to quit before enlisting in the military. Upon quitting the medication, she was depressed, worsened by her military service in Iraq. The PTSD manifests in a deep sense of guilt, and the client also has suicidal thoughts. She, however, has no nightmares. Other people in her life suggested that she gets therapy.
Past Psychiatric History:
- General Statement: The patient was in treatment for her depression until she was at the age of eighteen years, a period that she has been on anti-depressants. She is, however, being treated for PTSD for the first time.
- Caregivers (if applicable): She has no caregivers since she can care for her personal and professional needs.
- Hospitalizations: She has never been hospitalized
- Medication trials: The client has never been treated for PTSD but was on anti-depressants until eighteen.
- Psychotherapy or Previous Psychiatric Diagnosis: The patient reports on the various indications suggesting she may be having PTSD, for example, her sense of guilt. She is expressive of the multiple aspects of her life and how PTSD may have affected her. The PTSD has affected her everyday activities but has not caused nightmares.
Substance Current Use and History: The patient has been on anti-depressants until she was eighteen years old when she joined the army.
Family Psychiatric/Substance Use History: Her brother has a history of cannabis use.
Psychosocial History: The patient serves as a MOS 92M Mortuary Affairs Specialist in the army. She lives with her boyfriend L. off the military base. The PTSD affects her romantic relationship through her sense of guilt and the reportedly lost sex drive. The patient is avoidant of all social activities and prefers keeping to herself.
- Current Medications: The patient had been on anti-depressants until she was the age of eighteen years. She is currently not on medication.
- Allergies: The client has no known allergies.
- Reproductive Hx: Her menstrual cycle affects her PTSD and depression, whereby the symptoms are more intense during her menstrual cycles.
- GENERAL: The patient has lost her sex drive, associated with post-traumatic stress disorder. No weight loss, fatigue, weakness, chill, or fever were reported.
- HEENT: Throughout, nose, ears; no hearing loss, sore thought, running nose, congestion, or sneezing reported. Eyes: no yellow sclerae, double vision, blurred vision, or vision loss.
- SKIN: No rash or itching reported
- CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
- RESPIRATORY: No shortness of breath, cough, or sputum.
- GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
- GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color.
- NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
- MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
- HEMATOLOGIC: No anemia, bleeding, or bruising.
- LYMPHATICS: No enlarged nodes. No history of splenectomy.
- ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
Physical exam: Not applicable
- Depression disorder
The patient reports experiencing depression in her teenage and childhood. Additionally, other people in her life suggest that she gets treatment for PTSD. The patient shows self-awareness of her history of depression that has affected her health and interaction with others. Additionally, the patient was on anti-depressants which she no longer takes since joining the military.
Mental Status Examination: A.D is an African American female aged twenty years old. She depicts well-groomed in her military uniform at the time of the interview. Additionally, she is self-aware in her analysis of her mental health problem’s Impact on other aspects of her life. She does not report any negative impact of PTSD on her physical health. There’s no evidence of drug abuse in the attempt to mitigate her health problems. Additionally, the patient does not depict any evidence of delusion thinking. However, she reports having suicidal thoughts due to her depression and PTSD.
Passive suicidal ideations
This is the stream obsession with committing suicide and the desire to be no longer alive. Like the case of A.D., she reports social withdrawal and the desire to isolate herself from her films. She often feels helpless upon slightly disappointing news where she spends a lot of time crying. She reports that she believes that God has stopped her from committing suicide.
Depression is a mood disorder whereby the patient reports anger, loss, and sadness. A.D. shows signs of self-loathing through the therapy session, where she relays the numerous ways her life is affected by her mental health. Additionally, she has been treated for depression with the use of anti-depressants (Kaimal et al., 2018). The depression has, however, not affected other aspects of her life.
Post-traumatic Stress Disorder
PTSD is a mental health condition whereby the patient experiences severe anxiety, nightmares, and flashback to a terrifying event they witnessed or participated in in the past. Working as a MOS 92M Mortuary Affairs Specialist for the United States Army, A.D. is still disturbed by the condition of the bodies she was dealing with (Wallace & Sweetman, 2020). This would be the primary diagnosis; however, it would be important to attend to her predisposition to depression.
After a comprehensive psychiatric evaluation, it is evident that the patient could be suffering from both depression and post-traumatic stress disorder. Additionally, people who have observed them over long periods suggest that she has PTSD. This indicates that they have observed a change in her behavior over a long period. However, she was on anti-depressants before joining the military. However, the PTSD from her work in Iraq could have worsened her mental health. It would be important that she be treated for both depression and PTSD. She has continued to work indicates that her condition is moderately severe. Her support system is expected to play a critical role in her recovery.
In conclusion, A.D. may be experiencing PTSD due to her military service in Iraq or depression because she has not been taking her anti-depressants. It would be irresponsible to assume that the client has PTSD based on her military service. The depression that she had been earlier diagnosed with could cause her recent mental health issues. However, she reports having flashbacks of the dead bodies she was attending to PTSD is a vital consideration.
Kaimal, G., Walker, M. S., Herres, J., French, L. M., & DeGraba, T. J. (2018). Observational study of associations between visual imagery and measures of depression, anxiety and post-traumatic stress among active-duty military service members with traumatic brain injury at the Walter Reed National Military Medical Center. BMJ open, 8(6), e021448.
Wallace, D. M., & Sweetman, A. (2020). Comorbid sleep apnea, post-traumatic stress disorder, and insomnia: underlying mechanisms and treatment implications—a commentary on El Solh et al.’s Impact of low arousal threshold on treatment of obstructive sleep apnea in patients with post-traumatic stress disorder. Sleep and Breathing, 1-3.