Comprehensive Psychiatric Evaluation Note and Patient Case Presentation
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Comprehensive Psychiatric Evaluation Note and Patient Case Presentation
PRAC 6645 WEEK 4
Assignment 2: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation
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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.
- 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 disorderduring 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?
Required Readings (click to expand/reduce)
American Group Psychotherapy Association. (2007–2020). Practice guidelines for group psychotherapy. https://www.agpa.org/home/practice-resources/practice-guidelines-for-group-psychotherapy
American Psychiatric Association. (2020). Clinical practice guidelines. https://psychiatryonline.org/guidelines
Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
- Chapter 23, “Assessing Mood Disorders I: Depressive Disorders”
- Chapter 24, “Assessing Mood Disorders II: Bipolar Disorders”
Note: Use this website to log into Meditrek to report your clinical hours and patient encounters.
National Institute for Health and Care Excellence
U.S. Department of Veterans Affairs. (2020). VA/DoD clinical practice guidelines. https://www.healthquality.va.gov/
Document: Comprehensive Psychiatric Evaluation Note Template (Word document)
Document: Comprehensive Psychiatric Evaluation Note Exemplar (Word document)
Required Media (click to expand/reduce)
Center for Reality Therapy. (2010). Counseling with a group of not so eager clients [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/counseling-with-a-group-of-not-so-eager-clients
College of Nurses of Ontario CNO. (2018). Therapeutic nurse-client relationship: Maintaining boundaries [Video]. YouTube. https://www.youtube.com/watch?v=mCgmyyiZ9ek
The background and significance of the problem and a clear statement of the research purpose is provided. The search history is mentioned.
Content is well-organized with headings for each slide and bulleted lists to group related material as needed. Use of font, color, graphics, effects, etc. to enhance readability and presentation content is excellent. Length requirements of 10 slides/pages or less is met.
More depth/detail for the background and significance is needed, or the research detail is not clear. No search history information is provided.
Review of relevant theoretical literature is evident, but there is little integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are included. Summary of information presented is included. Conclusion may not contain a biblical integration.
Content is somewhat organized, but no structure is apparent. The use of font, color, graphics, effects, etc. is occasionally detracting to the presentation content. Length requirements may not be met.
The background and/or significance are missing. No search history information is provided.
Review of relevant theoretical literature is evident, but there is no integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are not included in the summary of information presented. Conclusion does not contain a biblical integration.
There is no clear or logical organizational structure. No logical sequence is apparent. The use of font, color, graphics, effects etc. is often detracting to the presentation content. Length requirements may not be met
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