Comprehensive Clinical Note
Nursebeauty
ComprehensivePsychiatricEvaluationAssignNRNP6645.docxComprehensive Psychiatric Evaluation Note and Patient Case Presentation
Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Comprehensive psychiatric evaluation notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you examined in a group setting during the last 4 weeks, using the Comprehensive Psychiatric Evaluation Note Template provided. You will then use this note to develop and record a case presentation for this patient.
· Review this week's Learning Resources and consider the insights they provide about clinical practice guidelines.
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· 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.
Learning Resources
https://www.agpa.org/home/practice-resources/practice-guidelines-for-group-psychotherapy
https://www.agpa.org/home/practice-resources/practice-guidelines-for-group-psychotherapy
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”
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https://www.healthquality.va.gov/
Required Media
https://www.youtube.com/watch?v=mCgmyyiZ9ek
To Prepare
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· 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 HealthyPeople 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.
CASE STUDY
Pt Name: J.S
Age: 41 Years old.
Diagnosis: Bipolar Disorder / PTSD
Chief Complain: Going through withdrawal.
Note: Pt is a 41 year old male, who presented to the clinic stating that he has been off his Percocet medication for 3 days now and does not want to go back to it. He used to take 10 mg x 6 daily. Pt is withdrawing and having some withdrawal symptoms like agitation, diarrhea, and chills. Pt started drinking a lot of alcohol to combat the withdrawal symptoms. He was refereed to get a prescription for Subioxone. Pt is on workers Comp. He was shot in 2008 which affected his T 12. Previously he also was amputated and due to a hole that was left in his wound, he developed sepsis. He has a colostomy bag and takes Melatonin 10 tablets to help him sleep. He also used to take cocaine and methamphetamine. He smokes occasionally. Goes to the GYM 5 am to 10 am. He dose not like interacting with others. He keeps to himself. Pt lives with daughter, granddaughter and son in-law. Pt was prescribed Subioxone 4 mg Q 2 hrs PRN. He is to follow up with the MD the next day to check on his withdrawal symptoms and the effect of Subioxone with the dosage.
