Comprehensive Psychiatric Evaluation Note
Assignment Instructions:
(1) Select a group patient for whom you conducted Psychotherapy for a MOOD DISORDER.
(2) Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided. There is also a completed template provided as an exemplar and guide.
(3) Include Five scholarly resources to support your assessment and diagnostic reasoning.
(4) SUBJECTIVE: Discuss what details the patient provided regarding their chief complaints, History of present illness, medication, Psychotherapy or previous psychiatric diagnosis, pertinent history and/or ROS, 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?
(5) OBSERVATION: What observation did you make during the psychiatric assessment.? Document accurately document the patient’s physical exam of system pertinent to chief complaints, HPI, and history. Diagnostic results, including labs, imaging, or other assessment needed to develop the differential diagnoses.
(6) ASSESSMENT: Discuss the patient’s mental status examination results. What were your differential diagnoses? (a) Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you choose 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.
(7) TREATMENT PLAN: Describe your treatment modality and your plan for psychotherapy. Explain the principles of psychotherapy that underlines 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?
(8) REFLECTION NOTES: What would you do differently in a similar patient evaluation? What are one health promotion activity and one patient education considerations for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
