Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. 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 you examined and record a case presentation for this patient.
To Prepare
- Impulse control or conduct disorder. 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.
- The Assignment
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.
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- 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 because 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.
- Rubric
Discuss Subjective data:
• Chief complaint
• History of present illness (HPI)
• Medications
• Psychotherapy or previous psychiatric diagnosis
• Pertinent histories and/or ROS—
Excellent 9 (9%) – 10 (10%)
Good 8 (8%) – 8 (8%)
Fair 7 (7%) – 7 (7%)
Poor 0 (0%) – 6 (6%)
Discuss Objective data:
• 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—
Excellent 9 (9%) – 10 (10%)
Good 8 (8%) – 8 (8%)
Fair 7 (7%) – 7 (7%)
Poor 0 (0%) – 6 (6%)
Discuss results of Assessment:
• Results of the mental status examination
• 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.—
Excellent 18 (18%) – 20 (20%)
Good 16 (16%) – 17 (17%)
Fair 14 (14%) – 15 (15%)
Poor 0 (0%) – 13 (13%)
Discuss treatment Plan:
• A treatment plan for the patient that addresses psychotherapy and rationales including a plan for follow-up parameters and referrals—
Excellent 18 (18%) – 20 (20%)
Good 16 (16%) – 17 (17%)
Fair 14 (14%) – 15 (15%)
Poor 0 (0%) – 13 (13%)
Reflections on this case.—
Excellent 5 (5%) – 5 (5%)
Good 4 (4%) – 4 (4%)
Fair 3.5 (3.5%) – 3.5 (3.5%)
Poor 0 (0%) – 3 (3%)
