I need a psychiatric evaluation attached is an exact example of what is to be done and the other is the directions for the evaluation
Psychiatric Evaluation (AKA Psychiatric History and Physical)
IMPORTANT:
Notes are to represent real clients seen by you in clinic and information must also be reflected in your InPlace or Typhon folder of clinical patients. Information leading to discovery of a “made up” note will be cause for course failure.
Each student will complete three (3) Psych Evals. Psych Evals are to be posted to the DB in a Copy & Paste fashion for ease of reading and reference. Please do not post a link to the document. These Psych Evals will stimulate discussion, questions, and critique by peers and instructors. Psych Evals are to be posted in weeks 3, 7, and 11 by Saturday at 11:59 pm EST. These are in addition to your case presentations. Discussion including at least one meaningful response to at least one of your peers’ Psych Evals should occur by Thursday at 11:59pm EST in weeks 4, 8, and 12 . A meaningful response is one that demonstrates critical thought. Refer to the Carlat, Zuckerman, and Kaplan & Sadock (Ch. 5) texts for assistance. Posts that are perfunctory or only minimally meeting all grading criteria do not necessarily qualify as “excellent” which would yield full points (100). This is true for both the initial post and the response post. One response post is considered to minimally meet criteria.
The evaluation is to be read by the clinical preceptor and INITIALED for accuracy. Please include additional information in italics, for instance what you may have done differently than your preceptor, or in addition to what was actually done. This should be an evaluation that is actually done by you. The initialed evaluation is to be submitted to the course instructor for verification via email in addition to posting to the DB.
Purpose: The psychiatric evaluation is designed to gather necessary information to assess the client’s condition as well as to begin establishing a therapeutic advanced practice psychiatric mental health nurse – client relationship. The information gathered during this process will allow the advanced practice psychiatric mental health nurse to develop a diagnosis from which a precise treatment plan is prescribed. Format should be in the H & P format outlined below. Grading rubric is also below.
H & P FORMAT: (Note: This example is not exhaustive and yours must include additional data such as elaboration of rationale, neurobiology, or other information important for an academic exercise but not necessarily appropriate for a clinical document in practice. Information found below under headings can be used as prompts but are not meant to be all inclusive of information needed.)
DEMOGRAPHIC INFORMATION
IDENTIFYING INFORMATION: The patient is a (age, marital, ethnicity, gender) who presents today for a psychiatric eval (reason/referral). Sources of information for this evaluation include pt report, collateral info from.., available old records. The patient was/was not able to give an account of his/her activities/life events/symptoms in a chronological order.
SUBJECTIVE DATA
CC:
HISTORY OF PRESENT ILLNESS: (SUBJECTIVE).
Should use the OLDCARTS acronym when trying to elicit characteristics of symptoms.
Remember to include pertinent negatives.
HPI MUST contain validation of diagnoses. Include your pertinent review of systems (ROS) here. You do not need to do an exhaustive review, only what is pertinent to the patient’s CC. Frequent symptoms that are reviewed in a psych eval are constitutional, neurological. Remember that the ROS is SUBJECTIVE. This is not the place for assessment findings ie. Lungs clear, BS present all 4 quad, skin is clear, appears to be responding to internal stimuli, etc…
PAST PSYCHIATRIC HISTORY:
Be sure to include previous treatment, response to treatment, and explore the seriousness and context of self harm or suicide attempts. Ask about hospitalizations or partial hospitalizations. If they have been diagnosed with psychiatric illness before, ask what type of provider made the diagnosis and why. This helps you understand the patient’s insight and understanding.
Psychotherapy
Hospitalizations
Suicide attempts
PREVIOUS PSYCHIATRIC MEDICATIONS: Question carefully about length of trials, dose, why d/c
CURRENT MEDICATIONS:
SUBSTANCE USE/ ADDICTIVE BEHAVIORS: If + is a higher risk for suicide. First use and circumstances surrounding use, consequences of use (social, legal, economic, relational, health), last use, pattern, CAGE- Cut down-Annoy-Guilt-Eyeopener. Detox/Rehab? How do they handle stress? How often is use, how much, what is the most you did in one day? Be wary of denial/minimization. Any withdrawal S&S? Ask specifically about classes of drugs , illicit and/or prescribed (marijuana, ETOH, stimulants like cocaine, meth, or Ritalin, opiates, synthetics, bath salts, designer drugs, and non controlled like gabapentin, Seroquel, or artane), nicotine, or caffeine (also comes in pill form) and route (“have you ever snorted anything? Injected anything? Taken pills that were not prescribed to you or taken your prescription other than as directed?” Routes include insufflation (snorting) IV, oral, sublingual, transdermal, anal, or vaginal).
Inquire about eating, spending, gaming, gambling patterns. May also begin to inquire about sexual habits.
FAMILY PSYCHIATRIC HISTORY:
Completed suicides
Good response to meds? If yes, which ones?
Dx by psych or self diagnosed?
MEDICAL HISTORY: Head injury, seizures, EEG, CT scan, review of pertinent labs, Current Medical Problems, chronic illnesses (lupus, fibromyalgia, arthritis, parkinsons, thyroid issues, cardiac disease, HTN, diabetes, cancer) any meds that have caused s&s? New onset of illness that causes stress? Last period, pregnancy test? Eating disorders? Sexual history
Medical Illnesses
History of Med Illness
Surgical history
Allergies
PSYCHOSOCIAL:
Ability to work and love. (work=ability to structure daily activities, meet expectations, relate adequately to peers and supervisors, take on level of responsibility. Long term relationship=ability to attend to others needs, control impulses, make a commitment.)
Childhood/developmental history, family of origin, siblings, birth order, relational status, marital status-how long, children, housing situation, education, employment, abuse, religious/spiritual beliefs, legal(consider antisocial or substance abuse if extensive)
Born and raised where/by whom/siblings/relationship status
Education/performance
Living situation
Marriage/relationships
Children
Employment
Legal
Abuse
ASSETS/STRESSORS:
OBJECTIVE DATA
MENTAL STATUS EXAM: (OBJECTIVE).
Must be in narrative form.
Include all elements and be as descriptive as possible. Please refer to Kaplan and Sadock text, Ch. 5, pgs. 201-205 and the Carlat or Robinson texts.
Mental Status Exam Elements- All Borderline Subjects Are Tough Troubled Characters
A- Appearance
Height, build, hair color, style, facial hair, body modifications, facial features, scars, grooming, hygiene, odors, clothing, make-up, impression of general appearance and memorable aspects.
B- Behavior
Attitude
Motor activity
S- Speech
General quality
Fluency
Amount
Rate
Tone
Volume
Prosody
Spontaneity or Latency
A- Affect
Qualities of Affect
Stability
Appropriateness
Range
Intensity
Mood as defined by patient. Usually in quotation marks
T- Thought process
Flow and processing of thought. Examples:
Circumstantiality
Clang associations
Fight of ideas
Perseveration
Thought blocking
T- Thought content
Suicidal ideation (SI), Homicidal ideation (HI), Violent ideation (VI). If + comment on intent, plan, and preparation
Psychotic ideation or perceptual disturbances. Examples:
Delusions or hallucinations
Obsessional thoughts
Compulsions
Ideas of reference
Paranoia (suspiciousness)
Significant themes related to diagnosis
C- Cognitive exam – consider educational attainment when interpreting results.
Alertness
Orientation
Concentration
Memory (long and short term)
Calculation
Fund of knowledge
Abstract reasoning
Insight
Judgment
PHYSICAL EXAM: (VS, HT, WT, LABWORK AND OTHER DIAGNOSTICS)
This section will vary in scope dependent on the setting.
DIFFERENTIAL:
DIAGNOSTIC IMPRESSION WITH FORMULATION:
RISK ASSESSMENT:
RECOMMENDATIONS AND PLAN WITH GOALS AND RATIONALES WITH NEUROBIOLOGY:
When providing treatment recommendations, be as holistic and comprehensive as possible. When describing rationales for these recommendations be as specific as possible. It is not sufficient to explain that a treatment is FDA indicated and then to outline the mechanism of action of the drug. Explain why you (or your preceptor) chose a particular drug or treatment in lieu of another. For instance, why escitalopram instead of citalopram or fluoxetine, or sertraline, etc…?
Remember to include all information that was actually done but also include, in italics, other or additional actions you would have taken or things you would have done differently.
Grading Rubric for Psychiatric Evaluations and Psychiatric Case Presentations
Category Unacceptable Acceptable Good Excellent
Demographic Data 0
Does not adequately convey topic. Missing all or most key elements. 1
Includes minimal identifying information. Primary source of information and reliability as well as reason for referral and patient understanding of referral are not included or are unclear. 3
Includes identifying information but leaves out some key elements. Primary source of information and reliability as well as reason for referral and patient understanding of referral are noted. 5
Includes identifying information including initials, age, gender, ethnicity. Primary source of information and reliability as well as reason for referral and patient understanding of referral are clear.
Subjective Data
History of Present Illness (HPI) 0
CC is not recorded. HPI does not reflect a chronological account of symptoms that are sufficiently descriptive to validate Dx per DSM-5 criteria. Pertinent negatives are not included. The longitudinal course of illness is nonexistent.
8
CC is clear. HPI provides an account of symptoms that are descriptive, nonchronological, without context, and do not clearly validate Dx per DSM-5 criteria. Few pertinent negatives are included. A longitudinal course of illness is unclear. Current medications are included.
14
CC is clear, concise and verbatim from pt. HPI is thorough yet concise and provides a chronological account of symptoms with some contextual factors that are sufficiently descriptive (oldcarts) to validate Dx per DSM-5 criteria. Pertinent negatives are included. A longitudinal course of illness is appreciable. Current psychiatric medications and response are included.
20
CC is clear, concise and verbatim from pt. HPI is thorough yet concise and provides a chronological account of symptoms and contextual factors that are sufficiently descriptive (oldcarts) to validate Dx per DSM-5 criteria. All pertinent negatives are included. A longitudinal course of illness is clear. Current psychiatric medications and response are included.
Past Psychiatric History 0
PPH contains no previous treatment Hx including previous Dx, hospitalizations, outpatient treatments, suicide attempts, self-harm, nor is there descriptions of previous medications with detailed trial and response history. Pertinent negatives are not included.
1
PPH contains sparse data regarding previous treatment including previous Dx, hospitalizations, outpatient treatments, suicide attempts, self-harm. Previous medication history is sparse and without detailed trial and response history. Pertinent negatives are unclear. 3
PPH contains most data regarding previous treatment including previous Dx, hospitalizations, outpatient treatments, suicide attempts, self-harm, and previous medications with detailed trial and response history. Pertinent negatives are also included. 5
PPH contains all previous treatment including previous Dx, hospitalizations, outpatient treatments, suicide attempts, self-harm, and previous medications with detailed trial and response history. Pertinent negatives are also included.
Substance Use History 0
Substance use history is not documented. No inclusion of addictive behavioral patterns. 1
Substance use history is documented but data is sparse. Pertinent negatives are unclear. Age of onset, duration, frequency/pattern of use, route of administration, last use, consequences of use are not all included. Not limited to illicit substances. Review of addictive behavioral patterns absent. 3
Complete substance use history is documented. Most pertinent negatives are documented. Age of onset, duration, frequency/pattern of use, route of administration, last use, consequences of use. Not limited to illicit substances. Inclusive of addictive behavioral patterns. 5
Complete substance use history is documented. Pertinent negatives are clear evidenced by appropriate pt. responses ie. “denies”. Age of onset, duration, frequency/pattern of use, route of administration, last use, consequences of use. Not limited to illicit substances. Inclusive of addictive behavioral patterns.
Past Medical History and Review of Systems (ROS) 0
Medical history is incomplete or absent. ROS is not complete or is not free from objective assessment data ie. “lungs clear” “BS present” 1
Medical history includes previous and current medical problems, surgeries, and allergies. ROS may be extraneous or incomplete for the presenting psychiatric problems and is not free from objective assessment data ie. “lungs clear” “BS present” 3
Medical history includes previous and current medical problems, surgeries, and allergies. ROS is germane to the presenting psychiatric problems but is not free from objective assessment data ie. “lungs clear” “BS present” 5
Medical history includes previous and current medical problems, surgeries, and allergies. ROS is germane to the presenting psychiatric problems and is free from objective assessment data ie. “lungs clear” “BS present”.
Family History Psychosocial and Developmental History 0
Family Hx is minimal or nonexistent and does not include identified relational status with current or historical psych illness, treatments, responses, suicides, or self-harm. Dev’t Hx minimally or does not include info regarding family of origin, siblings, birth order, family dynamics, relational patterns and status, educational, employment, abuse, spirituality, legal, military. Dev’t milestones for child & adolescents are not included 3
Family Hx includes some of the identified relational status with current or historical psych illness, treatments, responses, suicides, or self-harm. No indication if biologically related. Dev’t Hx includes minimal info regarding family of origin, siblings, birth order, family dynamics, relational patterns and status, educational, employment, abuse, spirituality, legal, military. Few dev’t milestones for child & adolescents are included 7
Family Hx includes current or historical psych illness without clear identification of relation, but does include treatments, responses, suicides, or self-harm. Dev’t Hx includes most info regarding family of origin, siblings, birth order, family dynamics, relational patterns and status, educational, employment, abuse, spirituality, legal, military. Dev’t milestones for child &
adolescents are included 10
Family Hx includes identified relational status with current or historical psych illness, treatments, responses, suicides, or self-harm. Indication if biologically related. Dev’t Hx includes info regarding family of origin, siblings, birth order, family dynamics, relational patterns and status, educational, employment, abuse, spirituality, legal, military. Dev’t milestones for child & adolescents are included
Objective Data
Mental Status Exam Physical Exam (as appropriate) vital signs, height, weight, labs or other relevant diagnostics. 0
MSE missing most elements.
Physical exam not documented 5
MSE contains all elements as outlined in addendum..
Is in narrative form and effectively and vividly describes the patient’s presentation. Concrete examples of all assessment results are included ie. “able to correctly interpret 2/3 simple proverbs” to validate documentation of “abstract thought intact”.
10
MSE contains all elements as outlined in addendum..
Is in narrative form and effectively and vividly describes the patient’s presentation. Concrete examples of all assessment results are included ie. “able to correctly interpret 2/3 simple proverbs” to validate documentation of “abstract thought intact”.
15
MSE contains all elements as outlined in addendum..
Is in narrative form and effectively and vividly describes the patient’s presentation. Concrete examples of all assessment results are included ie. “able to correctly interpret 2/3 simple proverbs” to validate documentation of “abstract thought intact”.
Assessment
0
Differential is impertinent to S&S or absent. Formulation does not support nor clearly outline thought process of diagnoses. Diagnoses tendered are not supported by criteria in the HPI description or substantiated with the MSE. 3
Differential is impertinent to S&S, formulation appears rudimentary and vague. Diagnoses are made per DSM-5 but are marginally reasonable. Criteria for diagnoses tendered are not explicit in the HPI description or substantiated with the MSE. 7
Differential is pertinent to S&S, formulation contains evidence of critical thought and subject knowledge, and reasonable diagnoses are made per DSM-5. Clearly met criteria for diagnoses tendered are explicit in the HPI description and substantiated with the MSE. 10
Differential is pertinent to S&S, formulation contains evidence of critical thought and subject knowledge, and reasonable diagnoses are made per DSM-5. Clearly met criteria for diagnoses tendered are explicit in the HPI description and substantiated with the MSE.
Plan
0
Treatment plan is presented without sound rationales. There is no evidence of synthesis of information or critical thought. 5
Evidence-based treatment plan is presented with minimal rationales. Rationales reflect the student’s marginal ability to choose treatments based not only on FDA approval or current evidence but also the nuances and unique characteristics of each. Treatment plan is reasonable but lacks comprehensiveness. There is minimal evidence of synthesis of information and critical thought. 10
Evidence-based treatment plan is presented with rationales. Level of detail reflects the student’s moderate ability to choose treatments based not only on FDA approval or current evidence but also the nuances and unique characteristics of each. Treatment plan is holistic and comprehensive. There is some evidence of the student’s synthesis of information and critical thought. 15
Evidence-based treatment plan is presented with detailed rationales. Level of detail reflects the student’s ability to choose treatments based not only on FDA approval or current evidence but also the nuances and unique characteristics of each. Treatment plan is holistic and comprehensive. There is strong evidence of the student’s synthesis of information and critical thought.
Writing, Support, APA 0
The format is not consistent with the example provided in the course. No recent, scholarly, peer- reviewed support of topic. Substantial grammar, spelling, and punctuation errors detracting from the assignment. Writing mechanics include many awkward or unclear passages and informal tone not consistent with formal scholarly work. Substantial errors in APA style based upon the required APA manuals listed on the course syllabi. 1
The format is marginally consistent with the example provided in the course. Limited recent (5-7 years), scholarly, peer- reviewed support of topics. Occasional spelling, grammar, and punctuation errors detracting from the assignment. Writing mechanics include awkward or unclear passages and informal tone not always consistent with formal scholarly work. Occasional errors in APA style based upon the required APA manuals listed on the course syllabi. 3
The format is fairly consistent with the example provided in the course. Clear, recent (5-7 years), scholarly, peer- reviewed support of topics. Minimal grammar, spelling, and punctuation errors. Writing mechanics include minimal awkward or unclear passages but are consistent with formal scholarly work. Minimal errors in APA style manuals listed on the course syllabi. 5
The format is consistent with the example provided in the course. Strong, recent (5-7 years), scholarly, peer- reviewed support of topics. No grammar, spelling, and punctuation errors. Writing mechanics are consistent with formal scholarly work. No errors in APA style based upon the required APA manuals listed on the course syllabi.
Rubric Addendum
Mental Status Exam Elements- All Borderline Subjects Are Tough Troubled Characters
A- Appearance
Height, build, hair color, style, facial hair, body modifications, facial features, scars, grooming, hygiene, odors, clothing, make-up, impression of general appearance and memorable aspects.
B- Behavior
Attitude
Motor activity
S- Speech
General quality
Fluency
Amount
Rate
Tone
Volume
Prosody
Spontaneity or Latency
A- Affect
Qualities of Affect
Stability
Appropriateness
Range
Intensity
Mood as defined by patient. Usually in quotation marks
T- Thought process
Flow and processing of thought. Examples:
Circumstantiality
Clang associations
Fight of ideas
Perseveration
Thought blocking
T- Thought content
Suicidal ideation (SI), Homicidal ideation (HI), Violent ideation (VI). If + comment on intent, plan, and preparation
Psychotic ideation or perceptual disturbances. Examples:
Delusions or hallucinations
Obsessional thoughts
Compulsions
Ideas of reference
Paranoia (suspiciousness)
Significant themes related to diagnosis
C- Cognitive exam – consider educational attainment when interpreting results.
Alertness
Orientation
Concentration
Memory (long and short term)
Calculation
Fund of knowledge
Abstract reasoning
Insight
Judgment
Physical Exam- Will be completed as appropriate to clinical setting. Physical exam results will vary in content. The instructor should use their discretion when considering the relative weight of this section.
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