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Pages:
12 pages/≈3300 words
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Style:
APA
Subject:
Health, Medicine, Nursing
Type:
Coursework
Language:
English (U.S.)
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MS Word
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Topic:

Comprehensive Psychiatric Evaluation

Coursework Instructions:

*/ You can use any patient with a psychiatric issue, this is for a PMHNP clinical class of Psychotherapy.
For this assignment, students will create a written comprehensive psychiatric evaluation of a patient they have seen in the clinic. Each student will use the Graduate Psychotherapy Note Template Download Graduate Psychotherapy Note Template to create a detailed psychiatric evaluation document. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive psychiatric evaluation is to be written using the attached template below.
S Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) (Links to an external site.) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS); Review of Systems (ROS).
O Objective data: Medications; Allergies; Past medical history; Family history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam, (Focused), and Mental Status Exam.
A Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes.
P Plan: Pharmacologic and Nonpharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up.
Other: Incorporate current clinical guidelines NIH Clinical Guidelines (Links to an external site.)or APA Clinical Guidelines (Links to an external site.), research articles, and the role of the PMHNP in your presentation.
Reminder: It is important that you complete this assessment using your critical thinking skills. You are expected to synthesize your clinical assessment, formulate a psychiatric diagnosis, and develop a treatment plan independently. It is not acceptable to document "my preceptor made this diagnosis." An example of the appropriate descriptors of the clinical evaluation is listed below. It is not acceptable to document “within normal limits.”
Submission Instructions:
The paper is to be clear and concise and students will lose points for improper grammar, punctuation and misspelling.
The paper should be formatted per current APA and 8-10 pages in length, excluding the title, abstract and references page. Incorporate a minimum of 5 current (published within last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work.
*/remember to answer the rubric section of Psychotherapy Note. Include in the Psychotherapy Note all of the following content in extensive detail: * therapeutic modalities * therapeutic intervention * goals of the therapy * progress to date. Thanks.

Coursework Sample Content Preview:

Comprehensive Psychiatric Evaluation Template
With Psychotherapy Note
Your Name
Subject and Section
Professor’s Name
Date
Encounter date: April 5, 2022
Patient Initials: L.R. Gender: Female Age: 27 years old Race: Filipino Ethnicity: Bicolano
Reason for Seeking Health Care: “I lost the love of my life, and I do not want to live anymore in a world like this.”
HPI: 6 months prior to consultation, the patient’s fiancé died. The two were riding a motorcycle when suddenly a large truck smashed onto them, resulting in a significant impact. When the patient woke up, they were pierced together by sharp metal but still alive. When the rescuers came, they cut the metal into two and were transferred to the hospital. However, upon arrival, the fiancé already had massive bleeding and bled to death while the patient watched in the emergency room. The patient could not talk to him as he gradually lost his life and thought that it was her fault because they would not have had that accident if she did not ask him to drive her to relieve her stress from work. Because of this, she lost the will to live and immediately wanted to die. However, her fiancé’s family told her that the fiancé would want her to live a life worth living. Initially, the patient wanted to die like he did and had multiple suicidal attempts. She refused to go to the psychiatrist for consultation and wanted to stay at her apartment the whole time. However, the patient tried to follow the will of his fiancé to try to live her life. Thus, she tried hard to eat, sleep, do recreational activities, and go to work.
Interim history revealed that the patient gradually lost her appetite, only eating a meal in small amounts once or twice a day. She also focused on work and refused to talk to or go out with her family and friends. She could not sleep properly and only had 3 to 4 hours of sleep daily, and during weekends, she was asleep for almost 18 hours a day. Due to this, she lost 25 kilograms in five months without attempting to reduce weight. She also claimed to have recurrent thoughts of death, wanting to be with her fiancé in the afterlife.
One month before the consultation, the patient resigned from her work and found a virtual assistant job online where she could work from home. However, after two weeks, she resigned because she could not concentrate on her work and had difficulty analyzing data. The other symptoms were persistent.
A few hours before consultation, the patient was brought to the emergency room for a suicidal attempt via hanging, and a suicide note was found beside her bed.
SI/HI: The patient had persistent suicidal ideations for six months but only had a suicide attempt a few hours before the consultation. No homicidal ideations were noted.
Sleep:  The patient sleeps 3 to 4 hours daily during weekdays and sleeps for 18 hours during weekends.  Appetite: Currently, the patient only eats one or two meals a day in small amounts and sometimes, no meal at all because she does not have an appetite despite ordering her favorite foods.
Allergies (Drug/Food/Latex/Environmental/Herbal): There are no known allergies to drugs, food, latex, env...
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