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