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 that you examined at your practicum site, using the Comprehensive Psychiatric Evaluation Note Template provided. You will then use this note to develop and record a case presentation for this patient. 

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
· Professor Hartung. (2020). 

Multisystemic therapy (MST) for at-risk youth and juveniles informational webinar

 Links to an external site.
[Video]. YouTube.

· Review this week’s Learning Resources and consider the insights they provide about impulse-control and conduct disorders. 
· Select a patient for whom you conducted psychotherapy 
for an impulse control or conduct disorder during the last 6 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 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 for your clinical patient.

Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complYou need to have JavaScript enabled in order to access this site.


PRAC-6645-9 (11/28/2022-02/12/2023)-PT27

Week 7: Assignment 2, Part 1

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PRAC-6645-9 (11/28/2022-02/12/2023)-PT27

Week 7: Assignment 2, Part 2

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CloseNRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Template

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


CC (chief complaint):


(include psychiatric ROS rule out)

Past Psychiatric History:

General Statement:

Caregivers (if applicable):


Medication trials:

Psychotherapy or
Previous Psychiatric Diagnosis:

Substance Current Use and History:

Family Psychiatric/Substance Use History:

Psychosocial History:

Medical History:

Current Medications:


Reproductive Hx:


Diagnostic results:


Mental Status Examination:

Differential Diagnoses:

Case Formulation and Treatment Plan:  


© 2021 Walden University

Page 1 of 3NRNP/PRAC 6645 Comprehensive Psychiatric

Evaluation Note Template


If you are struggling with the format or remembering what to include, follow the
Comprehensive Psychiatric Evaluation Template

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 assignments. After reviewing 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


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 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 examplCOMPREHENSIVE PSYCHIATRIC EVALUATION NOTE

Assignment 2: Week 7

Student name

College of Nursing-PMHNP, Walden University

PRAC 6645: Psychotherapy with Multiple Modalities Practicum

Faculty Name: Dr.

Assignment Due Date: Monday, October 18th, 2021



CC: “I am pretty tired, otherwise I am ok”.

HPI: T.M is a 27-year-old male who presented voluntarily for a psychiatric psychotherapy

session. He has a history of anxiety, poor sleep, impulsive behaviors, paranoia, depression,

irritability, anger, mood instability. He reports “manic” episodes in the back. The patient also has

a history of sadness, decreased energy, decreased motivation, decreased concentration, isolation,

and social anxiety. The patient also has a good response to the current medication regimen.

Past Psychiatric History:

 General Statement: The patient started treatment for mental health issues at a very young

age, which he did not disclose. He conveyed that he never felt the need of therapy until


 Caregivers (if applicable): The patient is considered an adult and provided consent for

this examination.

 Hospitalizations: The patient indicated a history of multiple inpatient hospitalizations.

 Medication trials: Although, admitted optimum results with many previous medications

regimen. The patient stated that he sometimes becomes non-compliant with his


 Psychotherapy or Previous Psychiatric Diagnosis: The patient was previously diagnosed

with MDD, substance abuse disorder, and adjustment disorder.

Substance Current Use and History: The patient does have a history of substance abuse and

recreational drugs. Currently uses cocaine on occasion and marijuana every day. The patient also

uses alcohol more than three times a week, mostly on the weekends.



Family Psychiatric/Substance Use History: The patient denies a family history of psychiatric

issues or substance abuse.

Psychosocial History: The patient moved to Florida with his family at the age of five and has

been residing in Orlando since then. The patient graduated from Oak Ridge High School, and

never pursued a college degree or a career.

Medical History: Patient denies any medical issues.

Current Medications: Bupropion HCL 300 mg tablet extended release 24hr by mouth every

morning, alprazolam 2mg tablet by mouth three times a day as needed, Rexulti (brexpiprazole) 1

mg tablet 1 tablet by mouth every night, Trintellix (vortioxetine) 20 mg tablet 1 tablet by mouth

every morning with meals.

 Allergies: Fluoxetine

 Reproductive Hx: The patient is not married or have any children.

 ROS:

 GENERAL: Decreased appetite and increased fatigue. No weight loss, fever, chills, weakness.

 HEENT: Eyes: Wear corrective glasses. No double vision, or yellow sclerae. Ears, Nose, Throat:

No hearing loss, sneezing, congestion, r

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