NRNP/PRAC 6645 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: (include psychiatric ROS rule out) 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: Objective: Diagnostic results: Assessment: Mental Status Examination: Differential Diagnoses: Reflections: Case Formulation and Treatment Plan: References © 2021 Walden University Page 1 of 3 1 7 Community Needs Assessment Tierainie C. Johnson Capella University Program Development and Evaluation In HS Professor Kelly White October 30, 2022 Community Needs Assessment Introduction Social problem defines notable behavior condition, presenting negative outcomes and consequences to a significant number of people, and is recognized as a problem that requires redress for an effective solution (Chambers and Bonk, 2013). As a community health expert and professional a consideration of a social problem are critical to accommodating identification, assessment, management, and control towards a notable goal of possessing positive implications for the overall population. Substance and drug abuse is one notable social problem with negative implications and consequences for a significant number of individuals in a community. According to the authors, there is significant National survey data that describes the impacts of substance and drug abuse in the USA (McLellan, 2017). In this case, there is specific attention to drug abuse among adolescents in California State, accommodating effective data for assessment to provide the critical framework in addressing the unmet community needs in managing drug abuse among youths. According to California Health Care Almanac, there is an increasing number of young with substance abuse and mental disorder. Similarly, key findings indicate that there is a serious emotional disturbance among youth and adolescents due to substance-related problems with one in eight teens reporting a major depressive episode in 2014–2015, up from one in 11 in 2011–2012. Similarly, 9% of adolescents of age between 12 and 17 reported the use of a substance such as alcohol (California Health Care Almanac, 2018). Admittedly, substance and drug abuse among youths and adolescents in California is an issue tha.

1. NRNP/PRAC 6645 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:
(include psychiatric ROS rule out)
Past Psychiatric History:
·
General Statement:
·
Caregivers (if applicable):
·
Hospitalizations:
·

2. 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:
Objective:
Diagnostic results:
Assessment:
Mental Status Examination:
Differential Diagnoses:
Reflections:
Case Formulation and Treatment Plan:
References
© 2021 Walden University

3. Page 1 of 3
1
7
Community Needs Assessment
Tierainie C. Johnson
Capella University
Program Development and Evaluation In HS
Professor Kelly White
October 30, 2022
Community Needs Assessment
Introduction
Social problem defines notable behavior condition, presenting
negative outcomes and consequences to a significant number of
people, and is recognized as a problem that requires redress for
an effective solution (Chambers and Bonk, 2013). As a
community health expert and professional a consideration of a
social problem are critical to accommodating identification,
assessment, management, and control towards a notable goal of

4. possessing positive implications for the overall population.
Substance and drug abuse is one notable social problem with
negative implications and consequences for a significant
number of individuals in a community. According to the
authors, there is significant National survey data that describes
the impacts of substance and drug abuse in the USA (McLellan,
2017). In this case, there is specific attention to drug abuse
among adolescents in California State, accommodating effective
data for assessment to provide the critical framework in
addressing the unmet community needs in managing drug abuse
among youths. According to California Health Care Almanac,
there is an increasing number of young with substance abuse
and mental disorder. Similarly, key findings indicate that there
is a serious emotional disturbance among youth and adolescents
due to substance-related problems with one in eight teens
reporting a major depressive episode in 2014–2015, up from one
in 11 in 2011–2012. Similarly, 9% of adolescents of age
between 12 and 17 reported the use of a substance such as
alcohol (California Health Care Almanac, 2018). Admittedly,
substance and drug abuse among youths and adolescents in
California is an issue that requires effective community
assessment to provide an effective platform for managing the
case and providing an improvement in the community. Thus,
providing effective attention to drug and substance abuse as a
social problem among adolescents and youths is critical in
Community Needs Assessment and improvements.
Community needs assessment steps
Assessing needs in a community is a systematic process that
requires stepwise planning and process for effective social
problem identification, assessment, management, and control to
achieve desirable results. In the need assessment, there are
notable steps in planning and conducting the social problem
assessment including defining the community, identifying assets
and resources, collecting community data, and creating an
action plan from the existing data for effective community
social problem change and management.

5. In defining the community, the need assessment program will
accommodate the population, attitudes and values, and
significant place. Fundamentally, the need assessment resonates
with California adolescents and youths as a significant
population to assess the unmet condition in drug and substance
abuse among youths. Consequently, defining the assessment in
the planning and conducting the need assessment will
encapsulate people, organization, location, and equipment.
Fundamentally, the concern of drug and substance abuse needs
to accommodate professionals such as community health
workers, the population, healthcare facilities and organizations,
locations such as health centers, and equipment and tools to
improve people's lives such as technology and medications. In
the planning and conducting of the program, accommodating
assets and personnel will determine the success and efficiency
of the program's performance and outcomes. After identifying
the assets and definition of the community social problem, there
will be a need to collect data from the community concerning
drug abuse and possible prevention techniques. Particularly, the
model will embrace Interviews, focus groups, and surveys in
understanding perceived and expressed community needs and
the social problem. Finally, the model will provide a platform
for creating an action plan to establish policies and change that
will provide a platform for solving and managing the unmet
social condition and possible suggestions for life improvement
in the community. Thus, the framework model for community
needs assessment will constitute defining the community,
identifying assets and resources, collecting community data, and
creating an action plan.
Cultural sensibility, ethics, diversity, and inclusion
Conducting a needs assessment is a crucial need to
accommodate the community; population and place diversity to
acknowledge ethics, inclusion, and cultural sensitivity.
According to the authors, community needs assessment
accommodates significant presentation on population diversity,
cultural sensitivity, and ethics for a comprehensive articulation

6. of needs that resonates with the population's critical values
(López et al. 2017). Specifically, the program will
accommodate specific attention to measurement considerations
to a diverse population, and accommodate beliefs, values, and
concerns on drug and substance abuse among adolescents and
youths in California. Noteworthy, the program in need
assessment will accommodate specific interventions for diverse
populations resonating with their beliefs, values, and perception
on the issue of drug and substance abuse. Moreover, the
program accommodates specific strategies such as diversity lens
collaboration and workforce diversity to ensure that diverse
communities within the locations accommodate and resonate
with culturally sensitive beliefs. Finally, the needs assessment
in the community will accommodate privacy, integrity, and
respect for autonomy as critical ethical issues in the community
needs assessment.
Result Projection
Several kinds of literature have accommodated critical research
and studies on the need to provide a strategic community needs
assessment for early, prevention, intervention, and management
of drugs and substances within a population. According to the
authors, early intervention and management of substance abuse
and related social problem provide positive and moderate drug
and substance abuse among the population (U.S. Department of
Health & Human Services, 2016). Additionally, the research to
investigate race and gender disparity in self-report and drug
addiction is an issue of concern whereby African-American
adolescents have less exposure to self-reporting than the White
adolescence in the USA (Johnson et al. 2022). Furthermore,
studies indicate that planning drug abuse prevention at
community levels, and applying strategic community-based
needs and programs posit a bidirectional relationship between
positive behavior change and community health performance.
Therefore, the findings resonate with the community needs
assessment goals, and project the outcomes of a positive
behavior change within the California Community, particularly

7. on adolescents and youths.
Logic Model
References
California Health Care Almanac (2018). Mental Health and
Substance Use: A Crisis for California’s Youth.
California Healthcare Foundation
.https://www.chcf.org/wp-
content/uploads/2018/12/AlmanacMentalHealthSUDYouth.pdf
Chambers, D., and Bonk, J. (2013).
Social Policy and Social Programs: A Method for the
Practical Public Policy Analyst, (6th Edition). Pearson
Deelen, A., Tomaszewski, R., Hager, K., Chen, N., & Palombi,
L. (2022). Relentless Stigma: A Qualitative Analysis of a
Substance Use Recovery Needs Assessment. Substance Abuse:
Research and Treatment, 16(2022).
https://doi.org/10.1177/11782218221097396
Johnson, M.E., Lloyd, S.L., Bristol, S.C. et al. (2022). Black
girls and referrals: racial and gender disparities in self-reported
referral to substance use disorder assessment among justice-
involved children.
Subst Abuse Treat Prev Policy 17, 68 (2022).
https://doi.org/10.1186/s13011-022-00462-6
López, M., Hofer, K., Bumgarner, E., & Taylor, D. (2017).
Developing Culturally Responsive Approaches to Serving
Diverse Populations: A Resource Guide for Community-Based
Organizations. National Research Center on Hispanic Children
and Families. https://www.nsvrc.org/sites/default/files/2017-
06/cultural-competence-guide.pdf
McLellan, T. (2017). Substance Misuse and Substance Use

8. Disorders: Why do they Matter in Healthcare?
Trans Am Clin Climatol Assoc. 2017; 128:112-130.
U.S. Department of Health & Human Services. (2016). FACING
ADDICTION IN AMERICA The Surgeon General’s Report on
Alcohol, Drugs, and Health.
https://www.ncbi.nlm.nih.gov/books/NBK424857/pdf/Bookshelf
_NBK424857.pdf
1
Defining the community
2
Identifying assets and resources
3
collecting community data
4
creating an action plan

9. NRNP/PRAC 6645 Comprehensive Psychiatric
Evaluation Note Template
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 assignments. After
reviewing full details of the rubric, you can use it as a guide.
In the
Subjective section, provide:
· Chief complaint

10. · 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
·
Read rating descriptions to see the grading standards!
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.
·
Read rating descriptions to see the grading standards!
In the
Assessment section, provide:
· Results of the mental status examination,

11. 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.
·
Read rating descriptions to see the grading standards!
Reflect on this case. Include 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.).
(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

12. CC (chief complaint): A
brief statement identifying why the patient is here. This
statement is verbatim of the patient’s own words about why they
are 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 who presents for
psychotherapeutic evaluation for anxiety. He is currently
prescribed sertraline by (?) which he finds ineffective. His PCP
referred him for evaluation and treatment.
Or
P.H. is a 16-year-old Hispanic female who presents for
psychotherapeutic evaluation for concentration difficulty. She is
not currently prescribed psychotropic medications. She is
referred by her mental health provider for 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. This section
contains the symptoms that is bringing the patient into your
office. The symptoms onset, the duration, the frequency, the
severity, and the 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

13. disorders. You will complete a psychiatric ROS to rule out other
psychiatric illnesses.
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

14. 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. (Or, 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.
Psychosocial 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 within
siblings)
· Who the patient currently lives with in a home? Are they
single, married, divorced, widowed? How many children?
· Educational Level
· Hobbies

15. · 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
Diagnostic results: Include any labs, X-rays, or other
diagnostics that are needed to develop the differential diagnoses
(support with evidenced and guidelines).

16. 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, pseudo
hallucinations, 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 yo 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. 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

17. 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!), social determinates of health,
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.).
Case Formulation and Treatment Plan.
Includes documentation of diagnostic studies that will be
obtained, referrals to other health care providers, therapeutic
interventions with psychotherapy, education, disposition of the
patient, and any planned follow-up visits. Each diagnosis or
condition documented in the assessment should be addressed in
the plan. The details of the plan should follow an orderly
manner.
*see an example below—you will modify to your
practice so there may be information excluded/included—what
does your preceptor document?
Example:
Initiation of (what form/type) of individual, group, or family
psychotherapy and frequency.
Documentation of any resources you provide for patient
education or coping/relaxation skills, homework for next
appointment.
Client has emergency numbers: Emergency Services 911, the
Client's Crisis Line
1-800-_______. Client instructed to go to nearest ER or
call 911 if they become actively suicidal and/or homicidal.

18. (only if you or preceptor provided them)
Reviewed hospital records/therapist records for collaborative
information; Reviewed PCP report (only if actually available)
Time allowed for questions and answers provided. Provided
supportive listening. Client appeared to understand discussion.
Client is amenable with this plan and agrees to follow treatment
regimen as discussed. (This relates to informed consent; you
will need to assess their understanding and agreement.)
Follow up with PCP as needed and/or for:
Write out what psychotherapy testing or screening
ordered/conducted, rationale for ordering
Any other community or provider referrals
Return to clinic:
Continued treatment is medically necessary to address chronic
symptoms, improve functioning, and prevent the need for a
higher level of care OR if one-time evaluation, say so and any
other follow up plans.
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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