Comprehensive psychiatric evaluation note

We're the ideal place for homework help. If you are looking for affordable, custom-written, high-quality and non-plagiarized papers, your student life just became easier with us. Click either of the buttons below to place your order.

Order a Similar Paper Order a Different Paper


develop and record a case presentation for this patient. 

To Prepare

  • Review this week’s Learning Resources and consider the insights they provide about clinical practice guidelines. 
  • Select patients for whom you conducted group psychotherapy for a mood disorder during the last 4 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. Include at least five scholarly resources to support your assessment and diagnostic reasoning.

Learning Resources

American Group Psychotherapy Association. (2007–2020).
Practice guidelines for group psychotherapy.

American Psychiatric Association. (2020).
Clinical practice guidelines.

Carlat, D. J. (2017).
The psychiatric interview (4th ed.). Wolters Kluwer.

· Chapter 23, “Assessing Mood Disorders I: Depressive Disorders”

· Chapter 24, “Assessing Mood Disorders II: Bipolar Disorders”

National Institute for Health and Care Excellence

U.S. Department of Veterans Affairs. (2020).
VA/DoD clinical practice guidelines.

To Prepare

· Review this week’s Learning Resources and consider the insights they provide about clinical practice guidelines. 

· Select 
a group patient for whom you conducted psychotherapy for a mood disorder during the last 4 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. Include at least five scholarly resources to support your assessment and diagnostic reasoning.

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.

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 Healthy People 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.

Client Initial: Mrs. A. J.
Age: 56 years,
Race: Caucasian,


1.Mood Disorder

2. Anxiety Disorder

2. Trauma and Stress-Related Disorder

Chief Complaints

Client shares that she has had anxiety and depression since she was 10yo. She has been prescribed meds over the years doesn’t like taking them long term. Client has a prescription for Xanax but has not taken in 3 months. Client hasn’t been able to get herself “back into a groove.” Client shares that it has been over the past year that it has become harder to get motivated. Normally, can eat right, exercise and meditate. Client shares a long history of trauma and loss. Comes from a small town in Maryland where many of her childhood friends and family have overdosed or committed suicide. Her sister has multiple mental health issues and has stolen her family’s life savings. Client states that she left home when she was eighteen and feels the only reason she survived is because she left.

History of Present Illness

Does client require assistance via a qualified interpreter?: No

If yes, was the client provided information on how to access an interpreter?: Not Applicable Verified the client’s identification and location People present at visit Client Relationship status Married Personal pronouns she/her/hers

Gender identity: Female

History of present illness checklist

Symptom How Long?, How Often?, Intensity, Aggravating Factors, Alleviating Factors,

Sleep not sleeping well, can stay awake past10 pm, sleep 3-4 hours daily and always have difficulty sleeping.

Appetite hasn’t eaten yet today at 3 pm, lack of appetite

Concentration okay Mood unpredictable great, really bad its internal Irritability 100% around her period Energy unpredictable

HPI Narrative (if you would prefer you can write as narrative instead here):

Patient states that she started experiencing increase in loss of appetite, inability to sleep for over a week.

Current Safety Status

Reviewed with client that sessions are not recorded, and confidentiality is maintained unless a patient is a danger to oneself, others or is court ordered.

Does the client require a safety plan at this time? No

Self-harm? Denied

Suicidal intention? Denied

Violent thoughts and/or impulses? Denied

Homicidal thoughts and/or impulses? Denied

Does the client feel safe at home? Yes

Does the client have access to weapons? Yes, locked up Past or present risk factors?

Exposure to Domestic Violence Substance Use lack of appetite, younger cocaine use

Past Medical History

Past inpatient hospitalizations, partial/residential programs, outpatient programs or provider, had sepsis at 3 yrs, hit by a drunk driver in 2011, torn aorta several hospitalizations related to this

Current inpatient hospitalizations, partial/residential programs, outpatient programs or providers: No

Past medications and dosages/efficacy/side effects allergic to sulfa and Secor took Klonopin briefly, Lexapro briefly

Current medication dosages/efficacy/side effects and client’s feelings about medications Xanax prn and skin medication

Is medication being taken as prescribed? Yes

Current providers to collaborate with for continuity of care (email [email protected] to request release for current providers) no

Client provided verbal authorization to collaborate with the providers listed above.

Medical Assessment

Significant past medical history: Torn aorta

Any concerns related to brain health or functioning? Trouble with memory, short term

Current non-psychiatric medications? skin meds

Allergies? Sulfa

Any Current Medical Conditions or Concerns? No

Client identified trauma: Physical, Mental, Emotional, Bullying, Intimate Partner Violence Traumatic Grief, Accident,

Does the client experience any of the following?

Intrusive Memories/Thoughts, Reliving the Event, Nightmares, Avoidance, Memory Loss, Hopelessness, Detachment

Lack of Interest in Previously Enjoyed Activities: Numbness, Outbursts, Guilt/Shame, Difficulty Concentrating, Hyper Vigilance.


Client reports meeting all appropriate developmental milestones on time. Developmental milestones ahead of developmental milestones, very bright intellectually

Family History: brother: opioid addict, sister: mental health issues, mom major anxiety and depression, aunt, and grandmother mental health.

Social History

Who does the client identify as their “family” (biological or chosen support system) mom dad brother

How Does the Client Describe Their Childhood? when she was 7yrs. old her sister started having serious mental health issues, stopped eating. client never felt safe as sister was difficult to manage. No history of adoption in the family, client lives with her husband who is a military/ marine. Client has many college credits in musical, business, and finance, but no degree. Past employment includes mortgage company, bartender but not currently working.

Does the Client Have any Past or Current Legal Involvement? Incarceration? History of/or Current Restraining Order Involvement? No

Support System: Peers, Friends, Colleagues, Community, husband, family, few very close friends from childhood

What Does the Client Identify as their Hobbies, Interests, or Activities? Had 2 dogs, 1 died recently. Training the dogs, cooking, exercise.


Caffeine; maybe 1 x a week and Alcohol; every night 2 glasses wine

Age of First Use? 16 years

Does the Client Express Concern About Any of the Above Substances? No concern

Does the Client’s Family/Job/Community Express Concerns About the Above Substances: No Have the Substances had an Impact on Family/Job/Community? No

Review of Systems (ROS)

Mental Status Exam

Appearance: Within Normal Limits

Attitude: Within Normal Limits

Behavior: Within Normal Limits

Psychomotor (involuntary movements, agitation, tics, tardive dyskinesia or chorea): Within Normal Limits

Mood: Notable depressed

Affect: Notable labile, tearful

Speech: Within Normal Limits

Thought process: Within Normal Limits

Thought content: Within Normal Limits

Perceptions (hallucinations or illusions): Within Normal Limits

Cognitive (alertness, attention, memory, executive function): Within Normal Limits

Orientation (alert and oriented to person, place, date and time): Within Normal Limits

Insight: Within Normal Limits good insight

Judgment: Within Normal Limits

Knowledge and fund of information appropriate to educational background: Within Normal Limits


Assessment Notes: Were you able to gather all the assessment data in the above intake questions? Fully Completed

Based on session what is your overall clinical picture of the client and their needs? Client has a long history of trauma, depression, and anxiety. She would benefit from a combination of talk therapy and medication. Multiple losses, mental illness in family of origin, financial crisis in family


Clinician suggested: Getting a notebook, writing down concerns and issues to discuss, nightly sleep meditation, deep breathing, and a thirty minute walk every day.

Have You Scheduled a Follow Up Session? If Yes, Date? Yes, 9/29/22 at 3p


Does the client need a psychiatric consult for medication? Yes, I think this client would do well with an SSRI. has tried Klonopin and Lexapro in the past didn’t like them.


Client was given a way to reach provider between sessions (contact number, email or instructed to contact clinic)

Clinical Diagnosis Formulation that Supports Diagnosis (rendered at time of diagnosis): Client is traumatized by the sheer volume of people she knows that have either overdosed or committed suicide. She has suffered from anxiety and depression from age seven when her sisters mental health began to show serious signs in the house


Post-traumatic stress disorder, chronic [ F43.12] Depression, unspecified [ F32.A ]Generalized anxiety disorder [ F41.1 ]


Treatment Notes

Initial Treatment Plan

Treatment Goals: Treatment Goals/Hopes Identified by Client

I attest that I have collaborated with the client listed above to identify their goals for the initial treatment session. The client is in agreement with this treatment goal(s) and has verbally given consent for this treatment plan.

NRNP/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 3

NRNP/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 example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)


CC (chief complaint): A
brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why they are 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 who presents for psychotherapeutic evaluation for anxiety. He is currently prescribed sertraline by (?) which he finds ineffective. His PCP referred him for evaluation and treatment.


P.H. is a 16-year-old Hispanic female who presents for psychotherapeutic evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her mental health provider for 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. This section contains the symptoms that is bringing the patient into your office. The symptoms onset, the duration, the frequency, the severity, and the 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. You will complete a psychiatric ROS to rule out other psychiatric illnesses.

Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic

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.

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. (Or, 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.

Psychosocial 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)

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.

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

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).



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, pseudo hallucinations, 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 yo 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. 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!), social determinates of health, 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.).

Case Formulation and Treatment Plan.

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions with psychotherapy, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.
*see an example below—you will modify to your practice so there may be information excluded/included—what does your preceptor document?


Initiation of (what form/type) of individual, group, or family psychotherapy and frequency.

Documentation of any resources you provide for patient education or coping/relaxation skills, homework for next appointment.

Client has emergency numbers: Emergency Services 911, the Client’s Crisis Line
1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)

Reviewed hospital records/therapist records for collaborative information; Reviewed PCP report (only if actually available)

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (This relates to informed consent; you will need to assess their understanding and agreement.)

Follow up with PCP as needed and/or for:

Write out what psychotherapy testing or screening ordered/conducted, rationale for ordering

Any other community or provider referrals

Return to clinic:

Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care OR if one-time evaluation, say so and any other follow up plans.

References (move to begin on next page)

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.

© 2021 Walden University

Page 1 of 3

Do you need academic writing help? Our quality writers are here 24/7, every day of the year, ready to support you! Instantly chat with a customer support representative in the chat on the bottom right corner, send us a WhatsApp message or click either of the buttons below to submit your paper instructions to the writing team.

Order a Similar Paper Order a Different Paper