Comprehensive Psychiatric Evaluation Note and Patient Case Presentation
Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. 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 at your practicum site, 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 impulse-control and conduct disorders.
· Select a patient for whom you conducted psychotherapy for an impulse control or conduct disorder during the last 6 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. All psychiatric evaluation notes must be signed, and each page must be initialed by your Preceptor. When you submit your note, you should include the complete comprehensive evaluation note as a Word document and pdf/images of each page that is initialed and signed by your Preceptor. You must submit your note using SafeAssign.
· Assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.
· 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 diagnostic criteria and is supported by the patient’s symptoms.
· Plan: What was your plan for psychotherapy (including one health promotion activity and one patient education strategy)? What was your plan for treatment and management, including alternative therapies? Include nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
· Reflection notes: What would you do differently with this patient if you could conduct the session again?
CC: I keep destroying my books and other things.”
B.O. is a 15-year-old African American male who presented for a psychiatric evaluation and treatment for impulse control and conduct disorder. He is presently not taking any psychotic medications. His mother brought him in for psychiatric evaluation due to his persistent disobedient, hostile behavior and lies at every given opportunity. The patient’s symptoms started to be noticeable three years ago when his parents’ recurrent disruptive disputes caused their divorce. Though, he does not signify any disobedient and insolent behaviors with little flare-ups when he is not aggravated and distraught.