Nrnpprac 6635 comprehensive psychiatric evaluation template

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation
Template
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6635: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date
Subjective:
CC (chief complaint):
HPI:
Past Psychiatric History:
· General Statement:
· Caregivers (if applicable):
· Hospitalizations:

· Medication trials:
· Psychotherapy or Previous Psychiatric Diagnosis:
Substance Current Use and History:
Family Psychiatric/Substance Use History:
Psychosocial History:
Medical History:
· Current Medications:
· Allergies:
· Reproductive Hx:
ROS:
· GENERAL:
· HEENT:
· SKIN:
· CARDIOVASCULAR:
· RESPIRATORY:
· GASTROINTESTINAL:
· GENITOURINARY:
· NEUROLOGICAL:
· MUSCULOSKELETAL:
· HEMATOLOGIC:
· LYMPHATICS:
· ENDOCRINOLOGIC:
Objective:
Physical exam: if applicable
Diagnostic results:
Assessment:
Mental Status Examination:
Differential Diagnoses:
Reflections:
References
© 2021 Walden University
Page 1 of 3
PLEASE FOLLOW THE INSTRUCTIONS AS INDICATED

BELOW:
1). ZERO (0) PLAGIARISM
2). AT LEAST 5 REFERENCES, NO MORE THAN 5 YEARS.
3). PLEASE SEE THE ATTACHED RUBRIC DETAILS,
PSYCHIATRIC COMPREHENSIVE EVALUATION
TEMPLATE, PSYCHIATRIC COMPREHENSIVE
EVALUATION EXEMPLAR, CASE STUDY HISTORY, CASE
STUDY TRANSCRIPTS.
4) PLEASE FOLLOW THE APA 7 WRITING
STYLE/FORMAT.
TRAINING 9
00:00:00BEGIN TRANSCRIPT:
00:00:00[sil.]
00:00:15OFF CAMERA Ms. Branning, Mr. Nehring asked
suggested you see me. He said your having some issues at
work.
00:00:20MS. BRANNING You could call them that.
00:00:20OFF CAMERA What kind of difficulty are you having
at work?
00:00:25MS. BRANNING Well Mr. Nehring wants to fire me.
00:00:30OFF CAMERA Why do you think Mr. Nehring wants to
fire you?
00:00:30MS. BRANNING Because Eric is in love with me. And
it's probably getting in the way. And he wants to fire me.
00:00:40OFF CAMERA Who is Eric?
00:00:40MS. BRANNING Eric is my supervisor.
00:00:45OFF CAMERA Are the two of you in a relationship?

00:00:45MS. BRANNING No! Eric has his own girlfriend, I
have my own boyfriend. But Mr. Nehring got it in his head that
this is my fault. And they've been ganging up against me.
00:01:00OFF CAMERA What happened to make you feel this
way?
00:01:00MS. BRANNING Eric is lustful for me. Lust. Lustful.
00:01:10OFF CAMERA Well has Eric done anything
inappropriate?
00:01:10MS. BRANNING No, he doesn't have to.
00:01:15OFF CAMERA What do you mean?
00:01:15MS. BRANNING Well, he has this way of walking
toward me and he gives me the easiest assignments to do and he
asks me to voice my opinion a lot in our weekly meetings. And
I'm beautiful. I mean, not to be boastful or anything but I'm a
strong woman. And people are attracted to that. And others, like
Mr. Nehring feel threatened by it. He probably feels I
could replace him in a couple years. And I could.
00:01:45OFF CAMERA But there have been no instances of
sexual harassment.
00:01:50MS. BRANNING No. And now they want to fire me,
and it's probably because they don't want me to get in the way
of their day. I'm probably a distraction or something.
00:02:00OFF CAMERA According to Mr. Nehring you haven't
made a sale in three weeks.
00:02:05MS. BRANNING Oh, it's been a slow time period. I
guess it wouldn't be bad thing if they fired me. I mean after all
of this, all the bad it's done for my health. You know I should
really sue for discrimination; you know the stress and the health
problems.
00:02:25OFF CAMERA You've been having health problems?
00:02:25MS. BRANNING Yes. Yes. It keeps getting worse.
00:02:30OFF CAMERA Can you describe it for me?
00:02:30MS. BRANNING Well you know there's this pain in
my neck, it aches, it spreads to my back, I think there's a lump,
right here. I'm really worried.
00:02:55OFF CAMERA And what do you feel is the cause?

00:02:55MS. BRANNING I told you, pain, suffering, broken
heart. I think it's cancer.
00:03:05OFF CAMERA Have you been seen by a doctor?
00:03:10MS. BRANNING No. But it's probably cancer. And it's
slowly killing me. And it's all because of them. And Eric's
obsession with me.
00:03:20OFF CAMERA Ms. Branning, I don't think you have to
worry; a broken heart can't cause cancer.
00:03:25MS. BRANNING You never know until it happens.
00:03:30[sil.]
00:03:30 END TRANSCRIPT
TRAINING 24
00:00:00 BEGIN TRANSCRIPT:
00:00:00[sil.]
00:00:15OFF CAMERA Your roommates, Rachel and Liz,
shared some information with me. They said that you were fine,
and that shortly after your aunt died, that you started acting in a
different sort of strange way. Started having thoughts and
hearing things that others couldn't hear.
00:00:35JESS They think I'm living in a movie. Rachel and Liz.
That's who they think I am. I see a lot of movies. So maybe
they're right. Maybe I am a movie
00:00:45OFF CAMERA I'm not sure I understand how you can
be a movie.
00:00:45JESS Because they listen to our apartment.
00:00:50[Whispers]
00:00:50JESS They listen from next door.
00:00:50OFF CAMERA Who listens?
00:00:55JESS Russian men and whores. They drill all night
long. That's how they send their information back. Drilling.
00:01:05OFF CAMERA Drilling. They send messages by
drilling?
00:01:10JESS Doesn't surprise me. Most people don't
understand.

00:01:15OFF CAMERA Your roommates said that your favorite
aunt that died, she's the one who raised you.
00:01:20JESS Maybe she did. Maybe she didn't. Who told you?
Can you prove it? I can't.
00:01:30OFF CAMERA Liz and Rachel told me.
00:01:30JESS Good for them.
00:01:35OFF CAMERA And your roommates said you had
some new neighbors that moved in. Are these the neighbors
you're talking about?
00:01:45JESS They're not neighbors. They're Russians. They
don't answer their door. I tried to banging on their door and
they didn't answer. Figures. I mean they only speak English.
They don't speak English, they speak Russian in code.
00:02:00OFF CAMERA You know, your roommate, Rachel, told
me your new neighbors speak Spanish. They speak Spanish.
00:02:10JESS They lie. But what do you expect?
00:02:15OFF CAMERA What do they do? Your neighbors?
00:02:20JESS I don't want to talk about this any more.
00:02:25OFF CAMERA You know, Jess, I imagine what you are
experiencing right now feels very frightening. I hear from a lot
of the people who, hear voices that maybe aren't there, that it's
very frightening. And it's upsetting. Are you experiencing
anything like that?
00:02:40JESS Yes. I hear them talking when no one else can. I
mean not Rachel, not Liz. That's why I went down to my car
yesterday. Because if I'm very, very still, the Russians can't
code me.
00:02:55OFF CAMERA What do you mean code you?
00:03:00JESS You know. You act like you don't know, but
you know.
00:03:05OFF CAMERA How long did you stay in your car?
00:03:10JESS Six hours. I watched them move in and out.
00:03:15OFF CAMERA So do you sometimes see things that
your roommates don't see?
00:03:20JESS No. But I know things that they don't know.
00:03:30OFF CAMERA Jess, I realize it is difficult sometimes

for people to tell me things but it really helps me with their
background. Has anything happened recently? Anything
traumatic?
00:03:40JESS I think that secret government papers are
traumatic. Like blueprints. I mean, they have blueprints of
buildings. My apartment is a building.
00:03:55OFF CAMERA What are the blueprints?
00:03:55JESS They're all over the walls. That's what they want.
00:04:00OFF CAMERA The neighbors?
00:04:00JESS The Russians. They're terrorists. You'll find out
too late.
00:04:10OFF CAMERA Has anyone else seen these blueprints
Jess?
00:04:10JESS I can stop them from seeing them. I covered the
walls, I marked up the walls. I just need more markers.
00:04:20OFF CAMERA Jess, do you drink alcohol or take
drugs?
00:04:25JESS My body is my temple. No.
00:04:30OFF CAMERA Have you been taking any prescription
medications?
00:04:35JESS Yes, I did. I was.
00:04:40OFF CAMERA So you stopped taking your
medications?
00:04:45JESS Yes, I stopped taking my medications. The
medications were part of the problem. But you know all about
that, don't you?
00:04:55OFF CAMERA Jess, do you have any thoughts of
hurting yourself, or hurting any other people?
00:05:00JESS Rachel and Lizzy? I don't think they're in on it.
Time will tell.
00:05:10[sil.]

TRAINING 29
00:00:00BEGIN TRANSCRIPT:
00:00:00[sil.]
00:00:15OFF CAMERA Mr. Feldman? I understand you called
us last week for an appointment.
00:00:20MR. FELDMAN My parents.
00:00:25OFF CAMERA Excuse me?
00:00:25MR. FELDMAN My parents called for the
appointment.
00:00:25OFF CAMERA Oh. Do you know why your parents
called for an appointment?
00:00:30MR. FELDMAN No.
00:00:35OFF CAMERA When your parents called me they said
you were having some difficulty in school. Where are you in
school?
00:00:50MR. FELDMAN State College.
00:00:50OFF CAMERA How long have you been at State
College?
00:00:55MR. FELDMAN My freshman year.
00:01:00OFF CAMERA And how is it going?
00:01:05MR. FELDMAN Fine.
00:01:10OFF CAMERA What courses are you taking at State?
00:01:15MR. FELDMAN In high school I took
advanced placement courses. Theoretical physics, advanced
calculus is what I'm taking now. Although I'm thinking about
double majoring in philosophy and physics.
00:01:35OFF CAMERA That's an interesting combination.
00:01:35MR. FELDMAN Yes, the mysteries of life. The courses
are mysteries, and just when you think you've understood it, it's
gone.
00:01:45OFF CAMERA Gone?
00:01:50MR. FELDMAN The totality of life precludes us from
repeating it. I mean what's the point?

00:02:00OFF CAMERA Do you have a roommate at state?
00:02:05MR. FELDMAN You could call him that.
00:02:10OFF CAMERA Can you tell me about him?
00:02:15MR. FELDMAN Oh no.
00:02:15OFF CAMERA Why not?
00:02:20[sil.]
00:02:25MR. FELDMAN He put a microwave in there, but I
know what that means. But I won't tell. Not a word.
00:02:35OFF CAMERA A microwave oven?
00:02:40MR. FELDMAN They had them in here too, in this
building. But they'll spare me, and they'll spare you too,
because you are with me, and what that's about a bleeding
degeneration of blood cells, bleeding the humanity from our
rightful destiny... but this room spies on us.
00:03:05OFF CAMERA I don't understand what you mean.
00:03:10MR. FELDMAN It's in the eyes. You can hold of
forever if you know how.
00:03:20OFF CAMERA Mr. Feldman, did you come here with
anyone else today?
00:03:25[sil.]
00:03:30MR. FELDMAN Sssshhhh.
00:03:35OFF CAMERA Mr. Feldman, I think I may need
to contact your parents.
00:03:45SymptomMedia Visual Learning for Behavioral Health
www.symptommedia.com
TRAINING 134
00:00:00 BEGIN TRANSCRIPT:
00:00:00SYMPTOMS MEDIA, LLC DISCLAIMS ALL
RESPONSIBILITY FOR ANY LIABILITY LOSS OR RISK,
PERSONAL OR OTHERWISE, WHICH IS INCURRED AS A
CONSEQUENCE, DIRECTLY OR INDIRECTLY, OF THE USE
AND APPLICATION OF ANY OF THE CONTENT
CONTAINED HEREIN.

00:00:10[sil.]
00:00:15UNKNOWN Hi, Mrs. Warren, nice to see you again.
How are you doing?
00:00:20WARREN You're with them.
00:00:20UNKNOWN Pardon me.
00:00:25WARREN, I know you are. But you won't tell me,
people like you never do.
00:00:30UNKNOWN I'm not sure that I follow.
00:00:30WARREN Sure. They dumb just like everybody
else. We're on to you.
00:00:40UNKNOWN Who do you mean by we?
00:00:45WARREN Mm-hmm.
00:00:45UNKNOWN You are not going to tell me?
00:00:50WARREN I don't need to tell you. You have eyes and
ears planted everywhere.
00:00:55UNKNOWN Everywhere meaning other places away
from the hospital…
00:01:00WARREN Everywhere, enough set.
00:01:00UNKNOWN Let me make sure I understand. Are you
saying you feel that I or someone else has been spying on you?
00:01:05WARREN I don't feel that. I know it. You and your
people had… I don't need to explain it, you already know.
00:01:15UNKNOWN You feel safe here in the emergency
department?
00:01:20WARREN There's nowhere that is safe. Don't pretend
like there is.
Week 7 Schizophrenia and Other Psychotic Disorders;
Medication Induced Movement Disorders
Training Title 9

Name: Ms. Nijah Branning
Gender: female
Age: 25 years old
T- 98.4 P- 80 R 18 128/78 Ht 5’0 Wt 120lbs
Background: Raised by parents, lives alone in Santa Monica,
CA. Only child. Works in office
supply sales, has a bachelor’s in business degree. Has medical
history of hypothyroidism,
currently treated with daily levothyroxine. Guarded and
declined to discuss past psychiatric
history. Denied family mental health issues, declined to allow
you to speak to parents for
collaborative information. Allergies: medical tape; menses
regular
Symptom Media. (Producer). (2016). Training title 9 [Video].
https://video-
alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-
9
Training Title 24
Name: Ms. Jess Cunningham
Gender: female
Age: 28 years old
T- 98.6 P- 86 R 20 120/70 Ht 5’2 Wt 126lbs
Background: Jess is brought for evaluation by her 2 roommates
who are concerned with
behaviors that began 12 days after Jess’s younger brother
committed suicide in front of her via
GSW after his girlfriend broke up with him. She is estranged
from her parents and her brother
was her only sibling. She is only sleeping 1–2 hours/24hrs; she
will only canned foods. She
smokes cannabis daily since she was 16, goes out on weekdays
2–3 times with her roommates
and has couple drinks of beer. She was prescribed alprazolam
1mg twice daily as needed by her

PCP for 15 days. She works as a bartender.
https://video-
alexanderstreetcom.ezp.waldenulibrary.org/wa tch/training-title-
24
Training Title 29
Name: Mr. Jay Feldman
Gender: male
Age:19 years old
T- 98.3 P- 69 R 16 106/72 Ht 5’7 Wt 117lbs
Background: European-American male. He has two younger
brothers, one with history of
ADHD, the other with history of anxiety. His mother has
anxiety; his father has paranoia
schizophrenia. He is home for spring break. He has no previous
medical problems.
Developmental milestones met as child. Appetite is inconsistent
and it seems he has lost 18lbs
since first going back to school in the fall. Jason has not acted
this way before but did have a
short trial of aripiprazole in the last six months of high school
for mild paranoia. He stopped the
medication after graduation as he could not tolerate due to side
effects of akathisia. Jason has
several friends but has not kept in touch with them since being
back home. He has not been
showering. Sleeping 4–5 hrs.
https://video-
29
Training Title 134
Name: Mrs. Bunny Warren

Gender: female
Age: 33 years old
Background: Bunny was brought in by her best friend, Patty,
after the police responded to her
home the fifth time today. The police was threatening to arrest
her for misuse of the 911
system, Bunny called you and you informed the police she
needed to go the emergency room.
She has been calling 911 saying people are looking in her
windows, standing across the street
watching her, stated they are watching for her husband to return
home so they can hurt him.
Today, she has a stomachache. She believes there is a snake
inside of her stomach which she
would like to have removed. She stopped eating 2 days ago
because of this.
During the assessment, the patient seemed on edge, anxious, and
paranoid. The patient has
history of scoliosis. This is her third presentation to this
hospital, she had one psychiatric
admission 2 years ago. No self-harm behaviors but has been
physically aggressive toward
others in the past. She is guarded and refuses to answer
questions whether there are memory
or concentration problems. She denies any recent head injuries.
She states that she has been
sleeping nightly, one or two hours at a time and waking up
throughout the night. Refuses labs,
refuses to have her vital signs obtained.
She obtains SSDI. She lives in Atlanta, GA. Bunny denies ever
using any drugs and drinks
occasionally, once a month. She has a sister who is ten years
older, both parents deceased in
the last two years. She has no children, her husband is out of
town, truck driver. Family history
includes that her father had two previous inpatient psychiatric

hospitalizations after bad drug
experiences in the 1970s, for one week each time. Mother had
diagnosis and ongoing
treatment for depression. Her paternal grandmother was state
hospitalized for several years.
She denies any past history of traumatic experiences, but her
friend does say that losing her
parents was hard for her emotionally. No history of military
service. No legal issues currently.
Has HS diploma. Allergies: haloperidol
https://video-
134
Rubric Detail
Select Grid View or List View to change the rubric's layout.
Content
Name: NRNP_6635_Week7_Assignment_Rubric
Grid ViewList View
Excellent
Good
Fair
Poor
Create documentation in the Comprehensive Psychiatric
Evaluation Template about the patient you selected.
In the Subjective section, provide:
• Chief complaint

• History of present illness (HPI)
• Past psychiatric history
• Medication trials and current medications
• Psychotherapy or previous psychiatric diagnosis
• Pertinent substance use, family psychiatric/substance use,
social, and medical history
• Allergies
• ROS
Points:
Points Range:
18 (18%) - 20 (20%)
The response throughly and accurately describes the patient's
subjective complaint, history of present illness, past psychiatric
history, medication trials and current medications,
psychotherapy or previous psychiatric diagnosis, pertinent
histories, allergies, and review of all systems that would inform

a differential diagnosis.
Feedback:
Points:
Points Range:
16 (16%) - 17 (17%)
The response accurately describes the patient's subjective
complaint, history of present illness, past psychiatric history,

medication trials and current medications, psychotherapy or
previous psychiatric diagnosis, pertinent histories, allergies,
and review of all systems that would inform a differential
diagnosis.
Feedback:
Points:
Points Range:
14 (14%) - 15 (15%)

The response describes the patient's subjective complaint,
history of present illness, past psychiatric history, medication
trials and current medications, psychotherapy or previous
psychiatric diagnosis, pertinent histories, allergies, and review
of all systems that would inform a differential diagnosis, but is
somewhat vague or contains minor innacuracies.
Feedback:
Points:
Points Range:
0 (0%) - 13 (13%)

The response provides an incomplete or inaccurate description
of the patient's subjective complaint, history of present illness,
past psychiatric history, medication trials and current
medications, psychotherapy or previous psychiatric diagnosis,
pertinent histories, allergies, and review of all systems that
would inform a differential diagnosis. Or, subjective
documentation is missing.
Feedback:
In the Objective section, provide:
• Physical exam documentation of systems pertinent to the
chief complaint, HPI, and history
• Diagnostic results, including any labs, imaging, or other
assessments needed to develop the differential diagnoses.
Points:

Points Range:
18 (18%) - 20 (20%)
The response thoroughly and accurately documents the
patient's physical exam for pertinent systems. Diagnostic tests
and their results are thoroughly and accurately documented.
Feedback:
Points:

Points Range:
16 (16%) - 17 (17%)
The response accurately documents the patient's physical exam
for pertinent systems. Diagnostic tests and their results are
accurately documented.
Feedback:
Points:

Points Range:
14 (14%) - 15 (15%)
Documentation of the patient's physical exam is somewhat
vague or contains minor innacuracies. Diagnostic tests and their
results are documented but contain minor innacuracies.
Feedback:
Points:

Points Range:
0 (0%) - 13 (13%)
The response provides incomplete or inaccurate documentation
of the patient's physical exam. Systems may have been
unnecessarily reviewed, or, objective documentation is missing.
Feedback:
In the Assessment section, provide:
• Results of the mental status examination, presented in
paragraph form.
• At least three differentials with supporting evidence. List
them from top priority to least priority. Compare the DSM-5
diagnostic criteria for each differential diagnosis and explain

what DSM-5 criteria rules out the differential diagnosis to find
an accurate diagnosis. Explain the critical-thinking process that
led you to the primary diagnosis you selected. Include pertinent
positives and pertinent negatives for the specific patient case.
Points:
Points Range:
23 (23%) - 25 (25%)
The response thoroughly and accurately documents the results
of the mental status exam.
Response lists at least three distinctly different and detailed
possible disorders in order of priority for a di fferential
diagnosis of the patient in the assigned case study, and it
provides a thorough, accurate, and detailed justification for

each of the disorders selected.
Feedback:
Points:
Points Range:
20 (20%) - 22 (22%)
The response accurately documents the results of the mental
status exam.

possible disorders in order of priority for a differential
provides an accurate justification for each of the disorders
selected.
Feedback:
Points:
Points Range:
18 (18%) - 19 (19%)

The response documents the results of the mental status exam
with some vagueness or innacuracy.
Response lists at least three different possible disorders for a
differential diagnosis of the patient and provides a justification
for each, but may contain some vaguess or innacuracy.
Feedback:
Points:

Points Range:
0 (0%) - 17 (17%)
of the results of the mental status exam and explanation of the
differential diagnoses. Or, assessment documentation is
missing.
Feedback:
Reflect on this case. Discuss what you learned and what you
might do differently. Also include in your reflection a
discussion related to legal/ethical considerations (demonstrate
critical thinking beyond confidentiality and consent for
treatment!), health promotion and disease prevention taking into
consideration patient factors (such as age, ethnic group, etc.),
PMH, and other risk factors (e.g., socioeconomic, cultural
background, etc.).

Points:
Points Range:
9 (9%) - 10 (10%)
Reflections are thorough, thoughtful, and demonstrate critical
thinking.
Feedback:

Points:
Points Range:
8 (8%) - 8 (8%)
Reflections demonstrate critical thinking.
Feedback:

Points:
Points Range:
7 (7%) - 7 (7%)
Reflections are somewhat general or do not demonstrate
critical thinking.
Feedback:

Points:
Points Range:
0 (0%) - 6 (6%)
Reflections are incomplete, inaccurate, or missing.
Feedback:
Provide at least three evidence-based, peer-reviewed journal
articles or evidenced-based guidelines that relate to this case to
support your diagnostics and differential diagnoses. Be sure
they are current (no more than 5 years old).

Points:
Points Range:
14 (14%) - 15 (15%)
The response provides at least three current, evidence-based
resources from the literature to support the assessment and
diagnosis of the patient in the assigned case study. The
resources reflect the latest clinical guidelines and provide
strong justification for decision making.
Feedback:

Points:
Points Range:
12 (12%) - 13 (13%)
resources from the literature that appropriately support the
assessment and diagnosis of the patient in the assigned case
study.
Feedback:

Points:
Points Range:
11 (11%) - 11 (11%)
Three evidence-based resources are provided to support
study, but they may only provide vague or weak justification.
Feedback:

Points:
Points Range:
0 (0%) - 10 (10%)
Two or fewer resources are provided to support assessment
and diagnosis decisions. The resources may not be current or
evidence based.
Feedback:

Written Expression and Formatting—Paragraph development
and organization:
Paragraphs make clear points that support well-developed ideas,
flow logically, and demonstrate continuity of ideas. Sentences
are carefully focused—neither long and rambling nor short and
lacking substance. A clear and comprehensive purpose
statement and introduction are provided that delineate all
required criteria.
Points:
Points Range:
5 (5%) - 5 (5%)
Paragraphs and sentences follow writing standards for flow,
continuity, and clarity.

A clear and comprehensive purpose statement, introduction, and
conclusion are provided that delineate all required criteria.
Feedback:
Points:
Points Range:
4 (4%) - 4 (4%)

continuity, and clarity 80% of the time.
Purpose, introduction, and conclusion of the assignment are
stated, yet they are brief and not descriptive.
Feedback:
Points:
Points Range:
3.5 (3.5%) - 3.5 (3.5%)

continuity, and clarity 60%–79% of the time.
Purpose, introduction, and conclusion of the assignment is
vague or off topic.
Feedback:
Points:

Points Range:
0 (0%) - 3 (3%)
continuity, and clarity less than 60% of the time.
No purpose statement, introduction, or conclusion were
provided.
Feedback:
Written Expression and Formatting—English writing
standards:
Correct grammar, mechanics, and punctuation

Points:
Points Range:
5 (5%) - 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors
Feedback:

Points:
Points Range:
4 (4%) - 4 (4%)
Contains a few (one or two) grammar, spelling, and
punctuation errors
Feedback:

Points:
Points Range:
3 (3%) - 3 (3%)
Contains several (three or four) grammar, spelling, and
punctuation errors
Feedback:
Points:

Points Range:
0 (0%) - 2 (2%)
Contains many (≥ five) grammar, spelling, and punctuation
errors that interfere with the reader’s understanding
Feedback:

Show Descriptions
Show Feedback
Create documentation in the Comprehensive Psychiatric
Evaluation Template about the patient you selected.
• Chief complaint
• History of present illness (HPI)
• Past psychiatric history
• Medication trials and current medications
• Psychotherapy or previous psychiatric diagnosis
• Pertinent substance use, family psychiatric/substance use,
• Allergies
• ROS--
Levels of Achievement:
Excellent
18 (18%) - 20 (20%)
The response throughly and accurately describes the patient's
subjective complaint, history of present illness, past psychiatric
history, medication trials and current medications,
psychotherapy or previous psychiatric diagnosis, pertinent
histories, allergies, and review of all systems that would inform
a differential diagnosis.

Good
16 (16%) - 17 (17%)
The response accurately describes the patient's subjective
complaint, history of present illness, past psychiatric history,
medication trials and current medications, psychotherapy or
previous psychiatric diagnosis, pertinent histories, allergies,
and review of all systems that would inform a differential
diagnosis.
Fair
14 (14%) - 15 (15%)
The response describes the patient's subjective complaint,
history of present illness, past psychiatric history, medi cation
trials and current medications, psychotherapy or previous
psychiatric diagnosis, pertinent histories, allergies, and review
of all systems that would inform a differential diagnosis, but is
somewhat vague or contains minor innacuracies.
Poor
0 (0%) - 13 (13%)

of the patient's subjective complaint, history of present illness,
past psychiatric history, medication trials and current
medications, psychotherapy or previous psychiatric diagnosis,
pertinent histories, allergies, and review of all systems that
would inform a differential diagnosis. Or, subjective
documentation is missing.
Feedback:
• Physical exam documentation of systems pertinent to the
chief complaint, HPI, and history
• Diagnostic results, including any labs, imaging, or other
assessments needed to develop the differential diagnoses.--
Excellent
18 (18%) - 20 (20%)
The response thoroughly and accurately documents the patient's

physical exam for pertinent systems. Diagnostic tests and their
results are thoroughly and accurately documented.
Good
16 (16%) - 17 (17%)
The response accurately documents the patient's physical exam
for pertinent systems. Diagnostic tests and their results are
accurately documented.
Fair
14 (14%) - 15 (15%)
Documentation of the patient's physical exam is somewhat
vague or contains minor innacuracies. Diagnostic tests and their
results are documented but contain minor innacuracies.
Poor
0 (0%) - 13 (13%)
The response provides incomplete or inaccurate documentation

of the patient's physical exam. Systems may have been
unnecessarily reviewed, or, objective documentation is missing.
Feedback:
• Results of the mental status examination, presented in
paragraph form.
• At least three differentials with supporting evidence. List
them from top priority to least priority. Compare the DSM-5
positives and pertinent negatives for the specific patient case. --
Excellent
23 (23%) - 25 (25%)
The response thoroughly and accurately documents the results

of the mental status exam.
provides a thorough, accurate, and detailed justification for
each of the disorders selected.
Good
20 (20%) - 22 (22%)
The response accurately documents the results of the mental
status exam.
provides an accurate justification for each of the disorders
selected.
Fair
18 (18%) - 19 (19%)

The response documents the results of the mental status exam
with some vagueness or innacuracy.
Response lists at least three different possible disorders for a
differential diagnosis of the patient and provides a justification
for each, but may contain some vaguess or innacuracy.
Poor
0 (0%) - 17 (17%)
of the results of the mental status exam and explanation of the
differential diagnoses. Or, assessment documentation is
missing.
Feedback:
Reflect on this case. Discuss what you learned and what you

might do differently. Also include in your reflection a
background, etc.).--
Excellent
9 (9%) - 10 (10%)
Reflections are thorough, thoughtful, and demonstrate criti cal
thinking.
Good
8 (8%) - 8 (8%)
Reflections demonstrate critical thinking.
Fair
7 (7%) - 7 (7%)

Reflections are somewhat general or do not demonstrate critical
thinking.
Poor
0 (0%) - 6 (6%)
Reflections are incomplete, inaccurate, or missing.
Feedback:
Provide at least three evidence-based, peer-reviewed journal
articles or evidenced-based guidelines that relate to this case to
support your diagnostics and differential diagnoses. Be sure
they are current (no more than 5 years old).--
Excellent

14 (14%) - 15 (15%)
resources from the literature to support the assessment and
diagnosis of the patient in the assigned case study. The
resources reflect the latest clinical guidelines and provide
strong justification for decision making.
Good
12 (12%) - 13 (13%)
resources from the literature that appropriately support the
study.
Fair
11 (11%) - 11 (11%)
Three evidence-based resources are provided to support
study, but they may only provide vague or weak justification.

Poor
0 (0%) - 10 (10%)
Two or fewer resources are provided to support assessment and
diagnosis decisions. The resources may not be current or
evidence based.
Feedback:
Written Expression and Formatting—Paragraph development
and organization:
Paragraphs make clear points that support well-developed ideas,
flow logically, and demonstrate continuity of ideas. Sentences
are carefully focused—neither long and rambling nor short and
lacking substance. A clear and comprehensive purpose
statement and introduction are provided that delineate all
required criteria.--

Excellent
5 (5%) - 5 (5%)
continuity, and clarity.
A clear and comprehensive purpose statement, introduction, and
conclusion are provided that delineate all required criteria.
Good
4 (4%) - 4 (4%)
continuity, and clarity 80% of the time.
Purpose, introduction, and conclusion of the assignment are
stated, yet they are brief and not descriptive.
Fair
3.5 (3.5%) - 3.5 (3.5%)

continuity, and clarity 60%–79% of the time.
Purpose, introduction, and conclusion of the assignment is
vague or off topic.
Poor
0 (0%) - 3 (3%)
continuity, and clarity less than 60% of the time.
No purpose statement, introduction, or conclusion were
provided.
Feedback:

Written Expression and Formatting—English writing standards:
Correct grammar, mechanics, and punctuation--
Excellent
5 (5%) - 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors
Good
4 (4%) - 4 (4%)
Contains a few (one or two) grammar, spelling, and punctuation
errors
Fair
3 (3%) - 3 (3%)
Contains several (three or four) grammar, spelling, and

punctuation errors
Poor
0 (0%) - 2 (2%)
Contains many (≥ five) grammar, spelling, and punctuation
errors that interfere with the reader’s understanding
Feedback:
Total Points:
100
Name: NRNP_6635_Week7_Assignment_Rubric

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation
Exemplar
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND
TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to
include, follow the Comprehensive Psychiatric Evaluation
Template AND the Rubric as your guide. It is also helpful to
review the rubric in detail in order not to lose points
unnecessarily because you missed something required. Below
highlights by category are taken directly from the grading rubric
for the assignment in Weeks 4–10. After reviewing the full
details of the rubric, you can use it as a guide.
· Chief complaint
· History of present illness (HPI)
· Past psychiatric history
· Medication trials and current medications
· Psychotherapy or previous psychiatric diagnosis
· Pertinent substance use, family psychiatric/substance use,
· Allergies
· ROS
· Read rating descriptions to see the grading standards!
· Physical exam documentation of systems pertinent to the chief
complaint, HPI, and history
· Diagnostic results, including any labs, imaging, or other
assessments needed to develop the differential diagnoses.
· Results of the mental status examination, presented in

paragraph form.
· At least three differentials with supporting evidence. List them
from top priority to least priority. Compare the DSM-5
positives and pertinent negatives for the specific patient case.
Reflect on this case. Include: Discuss what you learned and
what you might do differently. Also include in your reflection a
background, etc.).
(The comprehensive evaluation is typically the initial new
patient evaluation. You will practice writing this type of note in
this course. You will be ruling out other mental illnesses so
often you will write up what symptoms are present and what
symptoms are not present from illnesses to demonstrate you
have indeed assessed for all illnesses which could be impacting
your patient. For example, anxiety symptoms, depressive
symptoms, bipolar symptoms, psychosis symptoms, substance
use, etc.)
EXEMPLAR BEGINS HERE
CC (chief complaint): A brief statement identifying why the
patient is here. This statement is verbatim of the patient’s own
words about why presenting for assessment. For a patient with
dementia or other cognitive deficits, this statement can be
obtained from a family member.
HPI: Begin this section with patient’s initials, age, race, gender,
purpose of evaluation, current medication and referral reason.
For example:

N.M. is a 34-year-old Asian male presents for psychiatric
evaluation for anxiety. He is currently prescribed sertraline
which he finds ineffective. His PCP referred him for evaluation
and treatment.
Or
P.H., a 16-year-old Hispanic female, presents for psychiatric
evaluation for concentration difficulty. She is not currently
prescribed psychotropic medications. She is referred by her
therapist for medication evaluation and treatment.
Then, this section continues with the symptom analysis for your
note. Thorough documentation in this section is essential for
patient care, coding, and billing analysis.
Paint a picture of what is wrong with the patient. First what is
bringing the patient to your evaluation. Then, include a
PSYCHIATRIC REVIEW OF SYMPTOMS. The symptoms
onset, duration, frequency, severity, and impact. Your
description here will guide your differential diagnoses. You are
seeking symptoms that may align with many DSM-5 diagnoses,
narrowing to what aligns with diagnostic criteria for mental
health and substance use disorders.
Past Psychiatric History: This section documents the patient’s
past treatments. Use the mnemonic Go Cha MP.
General Statement: Typically, this is a statement of the patients
first treatment experience. For example: The patient entered
treatment at the age of 10 with counseling for depression during
her parents’ divorce. OR The patient entered treatment for detox
at age 26 after abusing alcohol since age 13.
Caregivers are listed if applicable.
Hospitalizations: How many hospitalizations? When and where
was last hospitalization? How many detox? How many
residential treatments? When and where was last
detox/residential treatment? Any history of suicidal or
homicidal behaviors? Any history of self-harm behaviors?
Medication trials: What are the previous psychotropic
medications the patient has tried and what was their reaction?
Effective, Not Effective, Adverse Reaction? Some examples:

Haloperidol (dystonic reaction), risperidone
(hyperprolactinemia), olanzapine (effective, insurance wouldn’t
pay for it)
Psychotherapy or Previous Psychiatric Diagnosis: This section
can be completed one of two ways depending on what you want
to capture to support the evaluation. First, does the patient
know what type? Did they find psychotherapy helpful or not?
Why? Second, what are the previous diagnosis for the client
noted from previous treatments and other providers. Thirdly,
you could document both.
Substance Use History: This section contains any history or
current use of caffeine, nicotine, illicit substance (including
marijuana), and alcohol. Include the daily amount of use and
last known use. Include type of use such as inhales, snorts, IV,
etc. Include any histories of withdrawal complications from
tremors, Delirium Tremens, or seizures.
Family Psychiatric/Substance Use History: This section contains
any family history of psychiatric illness, substance use
illnesses, and family suicides. You may choose to use a
genogram to depict this information. Be sure to include a
reader’s key to your genogram or write up in narrative form.
Social History: This section may be lengthy if completing an
evaluation for psychotherapy or shorter if completing an
evaluation for psychopharmacology. However, at a minimum,
please include:
Where patient was born, who raised the patient
Number of brothers/sisters (what order is the patient wi thin
siblings)
Who the patient currently lives with in a home? Are they single,
married, divorced, widowed? How many children?
Educational Level
Hobbies:
Work History: currently working/profession, disabled,
unemployed, retired?
Legal history: past hx, any current issues?
Trauma history: Any childhood or adult history of trauma?

Violence Hx:Concern or issues about safety (personal, home,
community, sexual (current & historical)
Medical History: This section contains any illnesses, surgeries,
include any hx of seizures, head injuries.
Current Medications: Include dosage, frequency, length of time
used, and reason for use. Also include OTC or homeopathic
products.
Allergies:Include medication, food, and environmental allergies
separately. Provide a description of what the allergy is (e.g.,
angioedema, anaphylaxis). This will help determine a true
reaction vs. intolerance.
Reproductive Hx:Menstrual history (date of LMP), Pregnant
(yes or no), Nursing/lactating (yes or no), contraceptive use
(method used), types of intercourse: oral, anal, vaginal, other,
any sexual concerns
ROS: Cover all body systems that may help you include or rule
out a differential diagnosis. Please note: THIS IS DIFFERENT
from a physical examination!
You should list each system as follows: General:Head: EENT:
etc. You should list these in bullet format and document the
systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or
yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing,
congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest
discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or
diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination, urgency, hesitancy,
odor, odd color

NEUROLOGICAL: No headache, dizziness, syncope, paralysis,
ataxia, numbness, or tingling in the extremities. No change in
bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or
stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat
intolerance. No polyuria or polydipsia.
Physical exam (If applicable and if you have opportunity to
perform—document if exam is completed by PCP): From head
to toe, include what you see, hear, and feel when doing your
physical exam. You only need to examine the systems that are
pertinent to the CC, HPI, and History. Do not use “WNL” or
“normal.” You must describe what you see. Always document in
head-to-toe format i.e., General: Head: EENT: etc.
Diagnostic results: Include any labs, X-rays, or other
diagnostics that are needed to develop the differential diagnoses
(support with evidenced and guidelines).
Assessment
Mental Status Examination: For the purposes of your courses,
this section must be presented in paragraph form and not use of
a checklist! This section you will describe the patient’s
appearance, attitude, behavior, mood and affect, speech, thought
processes, thought content, perceptions (hallucinations,
pseudohallucinations, illusions, etc.)., cognition, insight,
judgment, and SI/HI. See an example below. You will modify to
include the specifics for your patient on the above elements —
DO NOT just copy the example. You may use a preceptor’s way
of organizing the information if the MSE is in paragraph form.
He is an 8-year-old African American male who looks his stated
age. He is cooperative with examiner. He is neatly groomed and
clean, dressed appropriately. There is no evidence of any
abnormal motor activity. His speech is clear, coherent, normal
in volume and tone. His thought process is goal directed and
logical. There is no evidence of looseness of association or

flight of ideas. His mood is euthymic, and his affect appropriate
to his mood. He was smiling at times in an appropriate manner.
He denies any auditory or visual hallucinations. There is no
evidence of any delusional thinking. He denies any current
suicidal or homicidal ideation. Cognitively, he is alert and
oriented. His recent and remote memory is intact. His
concentration is good. His insight is good.
Differential Diagnoses:You must have at least three
differentials with supporting evidence. Explain what rules each
differential in or out and justify your primary diagnosis
selection. You will use supporting evidence from the literature
to support your rationale. Include pertinent positives and
pertinent negatives for the specific patient case.
Also included in this section is the reflection. Reflect on this
case and discuss whether or not you agree with your preceptor’s
assessment and diagnostic impression of the patient and why or
why not. What did you learn from this case? What would you do
differently?
Also include in your reflection a discussion related to
legal/ethical considerations (demonstrating critical thinking
beyond confidentiality and consent for treatment!), health
promotion and disease prevention taking into consideration
patient factors (such as age, ethnic group, etc.), PMH, and other
risk factors (e.g., socioeconomic, cultural background, etc.).
References (move to begin on next page)
You are required to include at least three evidence-based, peer-
reviewed journal articles or evidenced-based guidelines which
relate to this case to support your diagnostics and differentials
diagnoses. Be sure to use correct APA 7th edition formatting.
© 2021 Walden University
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Nrnpprac 6635 comprehensive psychiatric evaluation template

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