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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. 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 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. 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 © 2021 Walden University Page 1 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.). (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. Or 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. © 2021 Walden University Page 2 of 6 NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar 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? Educational Level Hobbies: 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) © 2021 Walden University Page 3 of 6 NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar 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. © 2021 Walden University Page 4 of 6 NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar 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). A ssessment 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) © 2021 Walden University Page 5 of 6 NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar 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: Mood Disorders Training Title 2 Name: Ms. Julie Houston Gender: female Age:19 years old T 98.1 P-78 R-18 119/74 Ht 5’2” Wt 184lbs Background: Recently started a business undergraduate program in Boston, MA after growing up and living in South Carolina her whole life. Grew up with both parents, two brothers, and one sister. Currently lives in off-campus housing with two other female roommates. Currently a full-time student, not employed. Not married, currently single. She has no previous psychiatric history; takes no medications. There is no psychiatric or substance use history for her or family. No legal hx NKDA Symptom Media. (Producer). (2016). Training title 2 [Video].https://videoalexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-2 Training Title 8 Name: Mrs. Leslie Tilman Gender: female Age: 32 years old T- 97.6 P- 97 R 22 149/98 Ht 5’3 Wt 245lbs Background: Recently had her first child two months ago. Currently married; stay at home mother after working in retail for 5 years. Grew up with both parents, one sister in Omaha, NE. Completed education through bachelor’s level, studying physics. Previous employment included research science as well as high school substitute teaching for 5 years prior to birth. No previous suicidal gestures; has uncle who committed suicide via GSW. She denied drugs/alcohol; uncle was opioid abuser. Hx of HTN-prescribed labetalol 100mg twice daily, admits to missing doses due to forgetting. No legal hx. Allergies: codeine Symptom Media. (Producer). (2016). Training title 8 [Video]. https://videoalexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-8 Training Title 18 Name: Ms. Ashley Domingo Gender: female Age:20 years old T-97.9 P-68 R-18 118/82 Ht 5’1 Wt 120lbs Background: Currently living off-base in California, active duty in the Army, MOS 92M Mortuary Affairs Specialist. Grew up in Houston, TX with both parents and one brother. Completed education through high school. Currently partnered. No children. Mother history of depression; brother hx of cannabis use. No medical history. No legal hx; NKDA Symptom Media. (Producer). (2017). Training title 18 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-18 Training Title 28 Name: Mrs. Louise Carson Gender: female Age: 49 years old T- 98.8 P- 99 R 20 150/88 Ht 5’5 Wt 135lbs Background: Currently living in Indianapolis, IN, working full-time as a logistics buyer in a medical facility. Has an MBA. Lives with her husband and three children, three boys who are all teenagers. Born and raised in Indianapolis, IN with her mother and two sisters. Father deceased in MVA when she was 2 years old. Sister has depression; mother has history of being a “functioning alcoholic”. Recently informed by her PCP she has a “fatty liver.” Allergies: latex Symptom Media. (Producer). (2016). Training title 28 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-28 Training Title 38 (same patient in video 43 but presentation of his illness pre-hospitalization) Name: Mr. Will Loman Gender: male Age:19 years old T- 98.6 P- 94 R 24 128/78 Ht 5’7 Wt 152lbs Background: Currently lives with his sister and two parents in Jacksonville, FL. Not currently employed. Completed high school, not currently in school. Hx of treatment for mood disorder began age 15, previous trials of Depakote, Olanzapine off and on, side effects of wt. gain. Has hx of a three-day hospitalization one year ago after found wandering on the side of the freeway, but he signed himself out ‘against medical advice.’ He refused medication due to previous experiences. Not currently partnered. He has been sexually inappropriate with comments to female neighbors; pulled his pants down in the mall. Denies any recent alcohol or substance use. Father has history of bipolar disorder. No history of self-harm behaviors, no family suicides. Mother reports he has slept 2–3 hours in past week, up spending money buying and playing new video games and says he is writing a book on how others can be a video game master. Appetite is decreased. No medical hx; Hx of trespassing as a juvenile. Has pending court date for indecent exposure. Allergies: PCN Symptom Media. (Producer). (2016). Training title 38 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-38 Training Title 43 (same patient in video 38 but presentation of his illness with hospital treatment) Name: Mr. Will Loman Gender: male Age:19 years old T- 98.2 P- 74 R 18 120/70 Ht 5’7 Wt 156lbs Background: Currently lives with his sister and two parents in Jacksonville, FL. Not currently employed. Completed high school, not currently in school. Hx of treatment for mood disorder began age 15, previous trials of Depakote, Olanzapine off and on, side effects of wt. gain. Has hx of a three-day hospitalization one year ago after found wandering on the side of the freeway, but he signed himself out ‘against medical advice.’ He refused medication due to previous experiences. Not currently partnered. He has been sexually inappropriate with comments to female neighbors; pulled his pants down in the mall. He is currently in hospital admitted one week ago, was initiated on lithium 300mg po three times daily and risperidone 1mg at bedtime. Denies any recent alcohol or substance use. Father has history of bipolar disorder. No history of self-harm behaviors, no family suicides. Mother reports he has slept 2–3 hours in past week, up spending money buying and playing new video games and says he is writing a book on how others can be a video game master. Appetite is decreased. No medical hx; hospital admission labs within normal ranges, UDS negative; Hx of trespassing as a juvenile. Has pending court date for indecent exposure. Allergies PCN Symptom Media. (Producer). (2016). Training title 43 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-43 Training Title 150 Name: Ms. Liliana Ball Gender: female Age:16 years old T- 97.4 P- 84 R 18 134/88 Ht 5’3 Wt 118lbs Background: Currently living with her parents in Tacoma, WA along with two young siblings. She is a sophomore in high school, not currently partnered, reports she is bisexual, lately having lot of unprotected sex that her parents don’t know about. She has been stealing money out of her mom’s purse to buy clothes, makeup, “and just other things.” She has history of treatment since age 7 for conduct disorder, depression, history of taking sertraline which worsened her irritability, aggression, impulsivity. She has been in a 3-month teen residential mental health facility discharged one month ago with lithium 300mg in am and 600mg at bedtime, aripiprazole 10mg in the morning. When discharged, her labs were within normal ranges and urine toxicology negative. She was positive for cannabis upon admission. Her parents believe she is hiding her medication as she has made comments “they slow me down; they crush my creative art.” She has hx of domestic violence toward her mother and 2 younger sisters as juvenile. No current legal issues. Her grandmother has hx of bipolar disorder; her mother and her maternal aunt have anxiety. She is sleeping 3–4hrs/24 hrs. Reports her appetite “is great.” She has no medical issues; has Nexplanon implant; hx of self-harm with cutting. Symptom Media. (Producer). (2018). Training title 150 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-150 Training Title 118 Name: Mr. Oscar Luna Gender: male Age: 52 years old T- 98.6 P- 90 R 24 140/84 Ht 5’8 Wt 170lbs Background: Born and raised in Leopold, IN. Is staying at a shelter after being homeless in MacArthur Park for 1 year in Los Angeles. He lost his apartment and his job working part-time as a dishwasher. Enjoys playing music. He has long hx of mental health treatment since age 14. Previous medication trials include lithium (toxicity), Depakote (wt gain), aripiprazole (akathisia), risperidone (dystonia), haloperidol (didn’t give a fair trial), quetiapine (wt gain), reports in past helpful medication was lurasidone, lamotrigine, olanzapine but states “they really squash my creative song writing though.” Poor historian. Never married, reports he is gay, no children; estranged from only living sister, parents deceased. He is not sure of his family mental health or substance use history but feels like he is most like his aunt, she has history of mental health treatment “but I’m not sure for what.” States that he got a master’s degree in music theory at Stanford. Admits to 1–3 drinks of alcohol when “playing music in the clubs”, denied illicit drugs, has history of overdose at age 28, history of 3 inpatient psychiatric hospitalization, most recent was 1 year ago. Allergies: doxycycline; hx of rosacea. Symptom Media. (Producer). (2018). Training title 118 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-118 Training Title 144 Name: Ms. Amy Hartford Gender: female Age: 32 years old T- 98.2 P- 74 R 18 120/70 Ht 5’1 Wt 150lbs Background: Currently lives in Phoenix, AZ, divorced with two children ages 10 and 8. Born and raised in Tucson, AZ with her mother and four sisters NKDA; no legal hx Symptom Media. (Producer). (2018). Training title 144 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-144 You will choose ONE video case study for your written assignment. Please use the Comprehensive Psychiatric Evaluation Template and Comprehensive Psychiatric Evaluation Exemplar as guides for your written assignments. For full credit, please read and follow the RUBRIC. If any information is not present, then you need to discuss why that information needs to be included. For example, if the video nor case history report has no mention of the patient’s allergy then please write that the allergy was not mentioned and why it is significant to include in your evaluation. The Comprehensive Psychiatric Evaluation Exemplar explains in detail the components of the Comprehensive Psychiatric Evaluation Template. Both the template and exemplar are located under the “Required Readings” For example, the Exemplar explains how to formulate a Chief Complaint (CC). Typically, CC is verbatim from patient ie “I am anxious.” In addition to reviewing the template and exemplar, please read the rubric carefully in order not to lose points. Below I am covering and highlighting common mistakes to help you obtain a 100% score. Create documentation in the Comprehensive Psychiatric Evaluation Template about the patient you selected. 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 18 (18%) - 20 (20%) The response throughly and accurately describes the patient's subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. 16 (16%) - 17 (17%) The response accurately describes the patient's subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. 14 (14%) - 15 (15%) The response describes the patient's subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies. 0 (0%) - 13 (13%) The response provides an incomplete or inaccurate description of the patient's subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Or, subjective documentation is missing. 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. 18 (18%) - 20 (20%) The response thoroughly and accurately documents the patient's physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented. 16 (16%) - 17 (17%) The response accurately documents the patient's physical exam for pertinent systems. Diagnostic tests and their results are accurately documented. 14 (14%) - 15 (15%) Documentation of the patient's physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies. 0 (0%) - 13 (13%) The response provides incomplete or inaccurate documentation of the patient's physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing. 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. 23 (23%) - 25 (25%) The response thoroughly and accurately documents the results of the mental status exam. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected. 20 (20%) - 22 (22%) The response accurately documents the results of the mental status exam. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the disorders selected. 18 (18%) - 19 (19%) The response documents the results of the mental status exam with some vagueness or innacuracy. Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vaguess or innacuracy. 0 (0%) - 17 (17%) The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or, assessment documentation is missing. Reflect on this case. 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.). 9 (9%) - 10 (10%) Reflections are thorough, thoughtful, and demonstrate critical thinking. 8 (8%) - 8 (8%) Reflections demonstrate critical thinking. 7 (7%) - 7 (7%) Reflections are somewhat general or do not demonstrate critical thinking. 0 (0%) - 6 (6%) Reflections are incomplete, inaccurate, or missing. Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old). 14 (14%) - 15 (15%) The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making. 12 (12%) - 13 (13%) The response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study. 11 (11%) - 11 (11%) Three evidence-based resources are provided to support assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification. 0 (0%) - 10 (10%) Two or fewer resources are provided to support assessment and diagnosis decisions. The resources may not be current or evidence based. Written Expression and Formatting—Paragraph development and organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. 5 (5%) - 5 (5%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. 4 (4%) - 4 (4%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet they are brief and not descriptive. 3.5 (3.5%) - 3.5 (3.5%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment is vague or off topic. 0 (0%) - 3 (3%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time. No purpose statement, introduction, or conclusion were provided. Written Expression and Formatting—English writing standards: Correct grammar, mechanics, and punctuation 5 (5%) - 5 (5%) Uses correct grammar, spelling, and punctuation with no errors 4 (4%) - 4 (4%) Contains a few (one or two) grammar, spelling, and punctuation errors 3 (3%) - 3 (3%) Contains several (three or four) grammar, spelling, and punctuation errors 0 (0%) - 2 (2%) Contains many (≥ five) grammar, spelling, and punctuation errors that interfere with the reader’s understanding Total Points: 100 Below I am covering and highlighting common mistakes to help you obtain a 100% score. From the rubric #2 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. 18 (18%) - 20 (20%) The response thoroughly and accurately documents the patient's physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented. The physical exam and diagnostic results are worth 20% Please do not just indicate "not applicable." If the physical exam is not conducted then please indicate what physical exam you will perform. Psychotropic medications can affect various systems i.e. neurological. For example, you can examine serotonin syndrome if you are prescribing SSRIs. One of the cardinal signs of serotonin syndrome is confusion. You should be examining TD on patients who are prescribed stimulants. Diagnostic: If none is conducted then discuss what labs you would be drawing to make sure the patient is safe. Pregnancy tests or urine drug screens may be warranted on patients. Hormone and vitamin levels may be considered. For example, some of the psychotropic meds can increase prolactin levels. Please support with evidence-based articles and guidelines. #3 25% Mental Status Exam (MSE) and Differentials 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. MSE – please read the Exemplar. 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. Differentials – please cite your work. You need to support your differentials with peer-reviewed articles. #5 15% for peer-reviewed articles Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old). Books are not considered peer-reviewed despite books going through a rigorous review process. #6 5% for Introduction, purpose statement and conclusion. An introduction should be about 4-5 sentences discussing your assignment. Your purpose statement will be part of your introduction. Typically, I prefer my purpose statement to be the last sentence of my introduction stating, “The purpose of this paper is to…..” You should have a separate reflection and conclusion per the rubric. Week (enter week #): (Enter assignment title) Student Name College of Nursing-PMHNP, Walden University NRNP 6635: Psychopathology and Diagnostic Reasoning Faculty Name Assignment Due Date Subjective: NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template CC (chief complaint): HPI: Past Psychiatric History: General Statement: Caregivers (if applicable): Hospitalizations: Medication trials: Psychotherapy or Previous Psychiatric Diagnosis: Substance Current Use and History: Family Psychiatric/Substance Use History: Psychosocial History: Medical History: Current Medications: Allergies: Reproductive Hx: ROS: GENERAL: HEENT: SKIN: CARDIOVASCULAR: RESPIRATORY: GASTROINTESTINAL: GENITOURINARY: NEUROLOGICAL: MUSCULOSKELETAL: © 2021 Walden University Page 2 of 3 NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template HEMATOLOGIC: LYMPHATICS: ENDOCRINOLOGIC: Objective: Physical exam: if applicable Diagnostic results: Assessment: Mental Status Examination: Differential Diagnoses: Reflections: References