psych eval
Grading Rubric for Psychiatric Evaluations and Psychiatric Case
Presentations Course: NSG-535-IKK - Adv Prac in Psych/MH Nurs I
Criteria Excellent Good Acceptable Unacceptable Criterion Score
Demographic
Data
/ 55 points
Includes identifying
information includ-
ing initials, age, gen-
der, ethnicity.
Primary source of
information and reli-
ability as well as rea-
son for referral and
patient understand-
ing of referral are
clear.
3 points
Includes identifying
information but
leaves out some key
elements. Primary
source of informa-
tion and reliability as
well as reason for
referral and patient
understanding of re-
ferral are noted.
1 point
Includes minimal
identifying informa-
tion. Primary source
of information and
reliability as well as
reason for referral
and patient under-
standing of referral
are not included or
are unclear.
0 points
Does not ade-
quately convey
topic. Missing all or
most key elements.
9/9/26, 9:48 AM Psychiatric Evaluation 1 (assignment folder) - NSG-535-IKK - Adv Prac in Psych/MH Nurs I - L.I.V.E. - Wilkes University
https://live.wilkes.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=709133&grpid=0&isprv=0&bp=0&ou=387997 1/11
Criteria Excellent Good Acceptable Unacceptable Criterion Score
Subjective Data
History of
Present Illness
(HPI)
/ 2020 points
CC is clear, concise
and verbatim from
pt. HPI is thorough
yet concise and pro-
vides a chronologi-
cal account of symp-
toms and contextual
factors that are suf-
ficiently descriptive
(oldcarts) to validate
Dx per DSM-5 crite-
ria. All pertinent
negatives are in-
cluded. A longitudi-
nal course of illness
is clear. Current psy-
chiatric medications
and response are
included.
14 points
CC is clear, concise
and verbatim from
pt. HPI is thorough
yet concise and pro-
vides a chronologi-
cal account of symp-
toms with some
contextual factors
that are sufficiently
descriptive (oldcarts)
to validate Dx per
DSM-5 criteria.
Pertinent negatives
are included. A lon-
gitudinal course of
illness is apprecia-
ble. Current psychi-
atric medications
and response are
included.
8 points
CC is clear. HPI pro-
vides 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 lon-
gitudinal course of
illness is unclear.
Current medications
are included.
0 points
CC is not recorded.
HPI does not reflect
a chronological ac-
count of symptoms
that are sufficiently
descriptive to vali-
date Dx per DSM-5
criteria. Pertinent
negatives are not in-
cluded. The longitu-
dinal course of ill-
ness is nonexistent.
9/9/26, 9:48 AM Psychiatric Evaluation 1 (assignment folder) - NSG-535-IKK - Adv Prac in Psych/MH Nurs I - L.I.V.E. - Wilkes University
https://live.wilkes.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=709133&grpid=0&isprv=0&bp=0&ou=387997 2/11
Criteria Excellent Good Acceptable Unacceptable Criterion Score
Past Psychiatric
History
/ 55 points
PPH contains all
previous treatment
including previous
Dx, hospitalizations,
outpatient treat-
ments, suicide at-
tempts, self-harm,
and previous medi-
cations with de-
tailed trial and re-
sponse history.
Pertinent negatives
are also included.
3 points
PPH contains most
data regarding pre-
vious treatment in-
cluding previous Dx,
hospitalizations,
outpatient treat-
ments, suicide at-
tempts, self-harm,
and previous medi-
cations with de-
tailed trial and re-
sponse history.
Pertinent negatives
are also included.
1 point
PPH contains sparse
data regarding pre-
vious treatment in-
cluding previous Dx,
hospitalizations,
outpatient treat-
ments, suicide at-
tempts, self-harm.
Previous medication
history is sparse and
without detailed
trial and response
history. Pertinent
negatives are
unclear.
0 points
PPH contains no
previous treatment
Hx including previ-
ous Dx, hospitaliza-
tions, outpatient
treatments, suicide
attempts, self-harm,
nor is there descrip-
tions of previous
medications with
detailed trial and re-
sponse history.
Pertinent negatives
are not included.
9/9/26, 9:48 AM Psychiatric Evaluation 1 (assignment folder) - NSG-535-IKK - Adv Prac in Psych/MH Nurs I - L.I.V.E. - Wilkes University
https://live.wilkes.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=709133&grpid=0&isprv=0&bp=0&ou=387997 3/11
Criteria Excellent Good Acceptable Unacceptable Criterion Score
Substance Use
History
/ 55 points
Complete substance
use history is docu-
mented. Pertinent
negatives are clear
evidenced by appro-
priate pt. responses
ie. “denies”. Age of
onset, duration,
frequency/pattern
of use, route of ad-
ministration, last
use, consequences
of use. Not limited
to illicit substances.
Inclusive of addic-
tive behavioral
patterns.
3 points
Complete substance
use history is docu-
mented. Most perti-
nent negatives are
documented. Age of
onset, duration,
frequency/pattern
of use, route of ad-
ministration, last
use, consequences
of use. Not limited
to illicit substances.
Inclusive of addic-
tive behavioral
patterns.
1 point
Substance use his-
tory is documented
but data is sparse.
Pertinent negatives
are unclear. Age of
onset, duration,
frequency/pattern
of use, route of ad-
ministration, last
use, consequences
of use are not all in-
cluded. Not limited
to illicit substances.
Review of addictive
behavioral patterns
absent.
0 points
Substance use his-
tory is not docu-
mented. No inclu-
sion of addictive be-
havioral patterns.
9/9/26, 9:48 AM Psychiatric Evaluation 1 (assignment folder) - NSG-535-IKK - Adv Prac in Psych/MH Nurs I - L.I.V.E. - Wilkes University
https://live.wilkes.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=709133&grpid=0&isprv=0&bp=0&ou=387997 4/11
Criteria Excellent Good Acceptable Unacceptable Criterion Score
Past Medical
History and
Review of
Systems (ROS)
/ 55 points
Medical history in-
cludes previous and
current medical
problems, surgeries,
and allergies. ROS is
germane to the pre-
senting psychiatric
problems and is free
from objective as-
sessment data ie.
“lungs clear” “BS
present”.
3 points
Medical history in-
cludes previous and
current medical
problems, surgeries,
and allergies. ROS is
germane to the pre-
senting psychiatric
problems but is not
free from objective
assessment data ie.
“lungs clear” “BS
present”
1 point
Medical history in-
cludes previous and
current medical
problems, surgeries,
and allergies. ROS
may be extraneous
or incomplete for
the presenting psy-
chiatric problems
and is not free from
objective assess-
ment data ie. “lungs
clear” “BS present”
0 points
Medical history is
incomplete or ab-
sent. ROS is not
complete or is not
free from objective
assessment data ie.
“lungs clear” “BS
present”
9/9/26, 9:48 AM Psychiatric Evaluation 1 (assignment folder) - NSG-535-IKK - Adv Prac in Psych/MH Nurs I - L.I.V.E. - Wilkes University
https://live.wilkes.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=709133&grpid=0&isprv=0&bp=0&ou=387997 5/11
Criteria Excellent Good Acceptable Unacceptable Criterion Score
Family History
Psychosocial and
Developmental
History
/ 1010 points
Family Hx includes
identified relational
status with current
or historical psych
illness, treatments,
responses, suicides,
or self-harm.
Indication if biologi-
cally related. Dev’t
Hx includes info re-
garding family of
origin, siblings, birth
order, family dynam-
ics, relational pat-
terns and status, ed-
ucational, employ-
ment, abuse, spiritu-
ality, legal, military.
Dev’t milestones for
child & adolescents
are included
7 points
Family Hx includes
current or historical
psych illness with-
out clear identifica-
tion of relation, but
does include treat-
ments, responses,
suicides, or self-
harm. Dev’t Hx in-
cludes most info re-
garding family of
origin, siblings, birth
order, family dynam-
ics, relational pat-
terns and status, ed-
ucational, employ-
ment, abuse, spiritu-
ality, legal, military.
Dev’t milestones for
child &
adolescents are
included
3 points
Family Hx includes
some of the identi-
fied relational status
with current or his-
torical psych illness,
treatments, re-
sponses, suicides, or
self-harm. No indi-
cation if biologically
related. Dev’t Hx in-
cludes minimal info
regarding family of
origin, siblings, birth
order, family dynam-
ics, relational pat-
terns and status, ed-
ucational, employ-
ment, abuse, spiritu-
ality, legal, military.
Few dev’t mile-
stones for child &
adolescents are
included
0 points
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, em-
ployment, abuse,
spirituality, legal,
military. Dev’t mile-
stones for child &
adolescents
9/9/26, 9:48 AM Psychiatric Evaluation 1 (assignment folder) - NSG-535-IKK - Adv Prac in Psych/MH Nurs I - L.I.V.E. - Wilkes University
https://live.wilkes.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=709133&grpid=0&isprv=0&bp=0&ou=387997 6/11
Criteria Excellent Good Acceptable Unacceptable Criterion Score
Objective Data
Mental Status
Exam Physical
Exam (as appro-
priate) vital
signs, height,
weight, labs or
other relevant
/ 1515 points
MSE contains all el-
ements as outlined
in addendum..
Is in narrative form
and effectively and
vividly describes the
patient’s presenta-
tion. Concrete ex-
amples of all assess-
ment results are in-
cluded ie. “able to
correctly interpret
2/3 simple
proverbs” to validate
documentation of
“abstract thought
intact”.
10 points
MSE contains all el-
ements as outlined
in addendum..
Is in narrative form
and effectively and
vividly describes the
patient’s presenta-
tion. Concrete ex-
amples of all assess-
ment results are in-
cluded ie. “able to
correctly interpret
2/3 simple
proverbs” to validate
documentation of
“abstract thought
intact”.
5 points
MSE contains all el-
ements as outlined
in addendum..
Is in narrative form
and effectively and
vividly describes the
patient’s presenta-
tion. Concrete ex-
amples of all assess-
ment results are in-
cluded ie. “able to
correctly interpret
2/3 simple
proverbs” to validate
documentation of
“abstract thought
intact”.
0 points
MSE missing most
elements.
Physical exam not
documented
9/9/26, 9:48 AM Psychiatric Evaluation 1 (assignment folder) - NSG-535-IKK - Adv Prac in Psych/MH Nurs I - L.I.V.E. - Wilkes University
https://live.wilkes.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=709133&grpid=0&isprv=0&bp=0&ou=387997 7/11
Criteria Excellent Good Acceptable Unacceptable Criterion Score
Assessment / 1010 points
Differential is perti-
nent to S&S, formu-
lation contains evi-
dence of critical
thought and subject
knowledge, and rea-
sonable diagnoses
are made per DSM-
5. Clearly met crite-
ria for diagnoses
tendered are explicit
in the HPI descrip-
tion and substanti-
ated with the MSE.
7 points
Differential is perti-
nent to S&S, formu-
lation contains evi-
dence of critical
thought and subject
knowledge, and rea-
sonable diagnoses
are made per DSM-
5. Clearly met crite-
ria for diagnoses
tendered are explicit
in the HPI descrip-
tion and substanti-
ated with the MSE.
3 points
Differential is imper-
tinent to S&S, for-
mulation appears
rudimentary and
vague. Diagnoses
are made per DSM-
5 but are marginally
reasonable. Criteria
for diagnoses ten-
dered are not ex-
plicit in the HPI de-
scription or substan-
tiated with the MSE.
0 points
Differential is imper-
tinent to S&S or ab-
sent. Formulation
does not support
nor clearly outline
thought process of
diagnoses.
Diagnoses tendered
are not supported
by criteria in the HPI
description or sub-
stantiated with the
MSE.
9/9/26, 9:48 AM Psychiatric Evaluation 1 (assignment folder) - NSG-535-IKK - Adv Prac in Psych/MH Nurs I - L.I.V.E. - Wilkes University
https://live.wilkes.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=709133&grpid=0&isprv=0&bp=0&ou=387997 8/11
Criteria Excellent Good Acceptable Unacceptable Criterion Score
Plan / 1515 points
Evidence-based
treatment plan is
presented with de-
tailed rationales.
Level of detail re-
flects the student’s
ability to choose
treatments based
not only on FDA ap-
proval or current ev-
idence but also the
nuances and unique
characteristics of
each. Treatment
plan is holistic and
comprehensive.
There is strong evi-
dence of the
student’s synthesis
of information and
critical thought.
10 points
Evidence-based
treatment plan is
presented with ra-
tionales. Level of de-
tail reflects the
student’s moderate
ability to choose
treatments based
not only on FDA ap-
proval or current ev-
idence but also the
nuances and unique
characteristics of
each. Treatment
plan is holistic and
comprehensive.
There is some evi-
dence of the
student’s synthesis
of information and
critical thought.
5 points
Evidence-based
treatment plan is
presented with mini-
mal rationales.
Rationales reflect
the student’s mar-
ginal ability to
choose treatments
based not only on
FDA approval or
current evidence
but also the nuances
and unique charac-
teristics of each.
Treatment plan is
reasonable but lacks
comprehensiveness.
There is minimal evi-
dence of synthesis
of information and
critical thought.
0 points
Treatment plan is
presented without
sound rationales.
There is no evidence
of synthesis of infor-
mation or critical
thought.
9/9/26, 9:48 AM Psychiatric Evaluation 1 (assignment folder) - NSG-535-IKK - Adv Prac in Psych/MH Nurs I - L.I.V.E. - Wilkes University
https://live.wilkes.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=709133&grpid=0&isprv=0&bp=0&ou=387997 9/11
Criteria Excellent Good Acceptable Unacceptable Criterion Score
Writing,
Support, APA
/ 55 points
The format is con-
sistent with the ex-
ample provided in
the course. Strong,
recent (5-7 years),
scholarly, peer- re-
viewed support of
topics. No grammar,
spelling, and punc-
tuation 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.
3 points
The format is fairly
consistent with the
example provided in
the course. Clear,
recent (5-7 years),
scholarly, peer- re-
viewed support of
topics. Minimal
grammar, spelling,
and punctuation er-
rors. Writing me-
chanics include min-
imal awkward or un-
clear passages but
are consistent with
formal scholarly
work. Minimal er-
rors in APA style
manuals listed on
the course syllabi.
1 point
The format is
marginally consis-
tent with the exam-
ple provided in the
course. Limited re-
cent (5-7 years),
scholarly, peer- re-
viewed support of
topics. Occasional
spelling, grammar,
and punctuation er-
rors detracting from
the assignment.
Writing mechanics
include awkward or
unclear passages
and informal tone
not always consis-
tent with formal
scholarly work.
Occasional errors in
APA style based
upon the required
APA manuals listed
on the course
syllabi.
0 points
The format is not
consistent with the
example provided in
the course. No re-
cent, scholarly,
peer- reviewed sup-
port of topic.
Substantial gram-
mar, 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 er-
rors in APA style
based upon the re-
quired APA manuals
listed on the course
syllabi.
9/9/26, 9:48 AM Psychiatric Evaluation 1 (assignment folder) - NSG-535-IKK - Adv Prac in Psych/MH Nurs I - L.I.V.E. - Wilkes University
https://live.wilkes.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=709133&grpid=0&isprv=0&bp=0&ou=387997 10/11
Total / 95
Overall Score
Level 4 63 points minimum
Level 3 30 points minimum
Level 2 1 point minimum
Level 1 0 points minimum
9/9/26, 9:48 AM Psychiatric Evaluation 1 (assignment folder) - NSG-535-IKK - Adv Prac in Psych/MH Nurs I - L.I.V.E. - Wilkes University
https://live.wilkes.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=709133&grpid=0&isprv=0&bp=0&ou=387997 11/11