NRNP 6635 PRAC Comprehensive Psychiatric Evaluation
Posted on: Monday, June 13, 2022 1:16:23 PM EDT
Please review the below tips.
- I suggest that you all spend time reviewing Chapter 5 of Kaplan and Saddock. If you have not watched the video, I posted reviewing the course exemplar please do so.
- The CC is a direct quote from the patient or caregiver if a caregiver includes that information.
- The HPI is a key component that takes practice. It should be clear and concise providing information that is pertinent to the signs and symptoms being presented without excessive information. The HPI should paint a picture of the client and is the foundation for the diagnosis.
See the examples below:
Mrs. TP voluntarily presents today with a severely depressed mood x 2 months that began after the death of her dog. She feels depressed more days than not and has crying spells 6 out of 7 days. They no longer find pleasure in gardening and have been written up at work due to missing work. She denies SI/HI. Reports feeling anxious daily with difficulty falling and staying asleep.
Mrs. TP reports feeling tired daily and fatigued, with psychomotor retardation of just laying in bed. She has had an increase in appetite and gained 15 lbs in the last 2 months. When she is having a depressing day she attempts to think about her grandchildren but this has not helped, she has avoided the dog park because it makes her depression worse. She denies previous episodes of depression.
What are the s/s present, what is the trigger/precipitating event, how often and how severe, what makes s/s better what makes it worse? I realize in the case study you may not be given the how often. That is when you insert below the HPI the following information was missing… This demonstrates that you understand the key components of an HPI.
- The psychosocial history is not just what is in the background document there is more information in that background document than what belongs in the psychosocial assessment you will need to be able to pick out from that background document what belongs in the psychosocial what belongs in the medical history, history, etc.
- You cannot say the Physical exam is Not applicable. An exam of some sort is always applicable. What are the client’s v/s, ht/wt, and BMI? Every case study had a set of vital signs in the background information. What can you see during the interview? Is the client’s skin pale? Was a tremor present? Any acute distress?? Keep in mind when you are practicing many insurance companies require at least 3 points of vital signs for payment of services. It is best to get in the habit of documenting this now.
- Diagnostic results: If you are given none in the case study tell me what you would order, why, and what evidence supports it. It may be blood work or CT of the head etc. Additionally, what assessment/screening tool would you use for this patient? Do not give every possible one but what you would order why, and, what evidence supports it. For example, if the patient expresses SI a suicide scale/assessment would be desirable.
- MSE: you must give the MSE in paragraph form. The exemplar in your course is helpful but page 213 of Kaplan & Saddock gives more detail and helpful information.
- Differential Diagnosis: I want to see that you can connect the presenting s/s to the diagnostic criteria. You can give background information about the diagnosis, but you must demonstrate that you can justify the diagnosis with the presentation and criteria. example” Mr.A.W. meets criteria A of depression as evidenced by ……..
- Reflections: Be sure that you are addressing each of the topics in the Assignment directions.
- Citations. You must have at least 3 peer review scholarly journals and evidence-based guidelines published within the last 5 years. Websites directed to patients are not scholarly and should not be used. To review correct APA citations, see the Writing Center Citations: Overview.
- Be sure you start your assignment with a Title page and an introduction. The introduction should be a brief paragraph that gives some background information about the diagnosis. Then end with a purpose statement.
- Writing concise sentences
Use the fewest and most efficient words possible to create information-packed sentences. Imagine that each word costs $20, and you have to budget carefully.
To clean up a wordy sentence:
- Keep your adjectives in front of your nouns:
Change a person who is lively to a lively person
Change a business that is known to be trustworthy to a trustworthy business
- Avoid beginning thoughts with it isor there are:
There are some people living in London who enjoy wearing hats that could be changed to the following:
Some people in London enjoy wearing hats
- Avoid redundancy:
I will study the theories, ideas, and models of three theorists could be I will study the ideas of three theorists
I do realize this is a lot of information, but I feel it will help you do your best on the 1st CPE submission.
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- CPE Video Review
Posted on: Monday, June 13, 2022, 2:36:51 PM EDT
Please watch the video below. In this video, I go over the assignment and the templates provided in the course. Additionally, I point out areas where students often struggle so It will help you to watch this video. If you have questions, please let me know.
CPE Video Review
Posted by: Tabitha Perrigo DNP PMHNP
Posted to: NRNP-6635-3/NRNP-6635C-3-Psychopathology Diag Reasoning-2022-Summer-QTR-Term-wks-1-thru-11-(05/30/2022-08/14/2022)-PT27
- CPE clarification
Posted on: Tuesday, June 14, 2022, 8:00:00 AM EDT
- You choose which case study to present listed in each week.
- You will need the 7th edition APA Title page and introduction that ends with a purpose statement at the beginning of your CPE. Then begin with the template provided in your resources. You will include a conclusion as well.
- If you have not already, please watch the video that was posted in the course announcements. It will help you better understand what is expected of this assignment.
4. When watching the case study video, you can view the transcripts and have the option of translating the transcript into other languages. You need to enter a word in the search bar then hit enter.
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
- 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-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR 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!), 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.).
(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.
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-TR 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 patient’s 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 the last hospitalization? How many detox? How many residential treatments? When and where was the 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 is the previous diagnoses 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 the patient was born, who raised the patient
Number of brothers/sisters (what order is the patient within siblings)
Who the patient currently lives in a home? Are they single, married, divorced, or widowed? How many children?
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, or surgeries, including any hx of seizures, or 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.
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 evidence 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! In 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 the examiner. He is neatly groomed and clean and dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, and 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 is 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 diagnostic impression 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!), 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.).
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 differential diagnoses. Be sure to use correct APA 7th edition formatting.