Comprehensive Psychiatric Evaluation Note
(Male,45, Mood Disorder)
A 45-year-old patient with a history of Depression disorder and previous suicidal attempts. Patient last hospitalization was two months ago after a failed suicide attempt by overdose, the patient was in the hospital for eight days; today is his fourth session after discharge. During the nursing assessment, the patient appears awake, alert, and oriented x3, he manifested feeling anxious due to some financial issues, otherwise manifested having no prominent symptoms of depression, anxiety, mania, or psychosis. In the session carried out today, the patient appeared calm, friendly, communicative, and relaxed. His participation today was average. After completing today’s activities, the patient showed improvements in relaxation through psychotherapy. The patient was active and participated fully in discussions today. The patient reports that his mood has improved in the past two weeks, and that he feels hopeful and with plans for the future. During the session, the clinician facilitated a discussion about stress management techniques. Psychoeducation provided regarding clarifying areas of difficulty and identifying coping skills. The clinician provided psychoeducation regarding medication compliance, and the patient was receptive. The patient was encouraged to continue follow-up psychotherapy to monitor his anxiety. Individual psychotherapy schedule in 4 weeks.
Assignment 2: Comprehensive Psychiatric Evaluation Note
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 (See above), using the Comprehensive Psychiatric Evaluation Note Template provided.
Instructions:
Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided. There is also a completed template provided as an exemplar and guide.
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-TR diagnostic criteria and is supported by the patient’s symptoms.
· Plan: Describe your treatment modality and your plan for psychotherapy. Explain the principles of psychotherapy that underline your chosen treatment plan to support your rationale for the chosen psychotherapy framework. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this psychotherapy session?
· 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.
**Include at least five scholarly resources to support your assessment and diagnostic reasoning. **
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