Comprehensive Evaluation Note from Individual with Mood Disorder | Cheap Nursing Papers

Comprehensive Evaluation Note from Individual with Mood Disorder

Comprehensive Evaluation Note from Individual with Mood Disorder

  • I will attach the template that needs to be filled out for this assignment. I will also include an example that you can refer to. See attached files. 
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  • 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.
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  • Review this week’s Learning Resources and consider the insights they provide about clinical practice guidelines.
  • 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. 

 

include subjective and objective data; 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?
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  • 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.
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  • 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?
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  • 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.

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