Description
The information needed to write the paper is attached.
Comprehensive Psychiatric Evaluation
Submit into the Black Board a comprehensive psychiatric evaluation on a adult and aging adult with a mental illness. Give a short synopsis of the case and why the patient has come to see you.
Comprehensive Psychiatric Evaluation
Source of Information
Identifying data – Do not include any real identifying data or location.
SUMMARY (Up to 150 words summarizing the case presentation and outcome.)
BACKGROUND (Why do you think this case is important-why did you decide to write it up?)
CASE PRESENTATION (Presenting features, medical/social/family history.)
Demographics should include: age, sex, who they live with, who they are accompanied by for your interview, who referred them to you.
Chief Complaint of Patient:
History of Present Illness
Current Medications
Past Psychiatric History
Past Psychiatric Medications
Substance Use/Abuse
Medical History
Allergies
Family History
Psychiatric and Addiction History
Developmental and Social History
MSE: Appearance and behavior Motor activity Speech Mood Affect Thought content (sensorium) Thought process Perceptual disturbances Cognition Abstract Reasoning Concentration Impulsivity Insight Judgment Threat to self or others Motivation Strength and Weakness
DIAGNOSTIC TESTS
CASE FORMULATION
DIFFERENTIAL DIAGNOSIS (with rationale)
DIAGNOSIS: (Include ICD 10 codes)
Treatment Plan: Pharmacology Psychotherapy Referrals Patient Education
OUTCOME AND FOLLOW-UP
Rubric
Exemplary
Proficient
Developing
Emerging
Absent
5
4
3
2
0
Identifying data SUMMARY BACKGROUND CASE PRESENTATION
Complete and Appropriate
Incomplete Appropriate
Complete Not all appropriate
Partially complete Not all appropriate
None present
10
7
5
3
0
Chief Complaint History of Present Illness Current Medications Past Psychiatric History Past Psychiatric Medications Substance Use/Abuse
Complete and Appropriate
Incomplete Appropriate
Complete Not all appropriate
Partially complete Not all appropriate
None present
10
8
6
4
0
Medical History Allergies Family History – Psychiatric and Addiction History. Developmental and Social History
Complete and Appropriate
Incomplete Appropriate
Complete Not all appropriate
Partially complete Not all appropriate
None present
5
4
3
2
0
DIAGNOSTIC TESTS
Complete and Appropriate
Incomplete Appropriate
Complete Not all appropriate
Partially complete Not all appropriate
None present
10
8
6
4
0
Mental Status Exam Strength and Weakness
Complete and Appropriate
Incomplete Appropriate
Complete Not all appropriate
Partially complete Not all appropriate
None present
15
10
8
5
0
Case Formulation
Complete and Appropriate
Incomplete Appropriate
Complete Not all appropriate
Partially complete Not all appropriate
None present
20
15
10
5
0
Differential Diagnoses with rationale Diagnosis with DSM coded
Complete and Appropriate
Incomplete Appropriate
Complete Not all appropriate
Partially complete Not all appropriate
None present
15
10
8
5
0
Treatment Plan: Pharmacology Psychotherapy Referrals Patient Education
Complete and Appropriate
Incomplete Appropriate
Complete Not all appropriate
Partially complete Not all appropriate
None present
10
8
6
4
0
FOLLOW-UP DISCUSSION Professional Presentation Written or Oral
Complete And professionally presented
Incomplete but Professionally presented
Complete But needs assistance with grammar or set-up or dictation organization
Incomplete and not professionally presented
Not professionally done
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