Family Assessment and Psychotherapeutic Approaches

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To prepare:

  • Review this week’s Learning Resources and reflect on the insights they provide on family assessment. Be sure to review the resource on psychotherapy genograms.
  • Download the Comprehensive Psychiatric Evaluation Note Template and review the requirements of the documentation. There is also an exemplar provided with detailed guidance and examples.
  • View the Mother and Daughter: A Cultural Tale video in the Learning Resources and consider how you might assess the family in the case study.

THE ASSIGNMENT

Document the following for the family in the video, using the Comprehensive Evaluation Note Template: 

  • Chief complaint
  • History of present illness
  • Past psychiatric history
  • Substance use history
  • Family psychiatric/substance use history
  • Psychosocial history/Developmental history
  • Medical history
  • Review of systems (ROS)
  • Physical assessment (if applicable)
  • Mental status exam
  • Differential diagnosis—Include a minimum of three differential diagnoses and include how you derived each diagnosis in accordance with DSM-5-TR diagnostic criteria
  • Case formulation and treatment plan
  • Include a psychotherapy genogram for the family

Note: For any item you are unable to address from the video, explain how you would gather this information and why it is important for diagnosis and treatment planning. 

 

Reading resources 

 

 

Required media 

 

 

*This is the EXEMPLAR 

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 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 
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.

 

 

NRNP/PRAC 6645 Comprehensive Psychiatric 
Evaluation Note Template
© 2021 Walden University Page 3 of 6
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. (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
• Work History: currently working/profession, disabled, unemployed, retired?
• Legal history: past hx, any current issues?

 

 

NRNP/PRAC 6645 Comprehensive Psychiatric 
Evaluation Note Template
© 2021 Walden University Page 4 of 6
• 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).
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 

 

 

 

**Please use the following Template for the assignment 

 

Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6645: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date

 

 

© 2021 Walden University Page 2 of 3
NRNP/PRAC 6645 Comprehensive Psychiatric 
Evaluation Note Template
CC (chief complaint): 
HPI: 
Past Psychiatric History: 
ï‚· General Statement: 
ï‚· Caregivers (if applicable):
ï‚· Hospitalizations: 
ï‚· Medication trials: 
ï‚· Psychotherapy or Previous Psychiatric Diagnosis: 
Substance Current Use and History: 
Family Psychiatric/Substance Use History: 
Psychosocial History: 
Medical History: 
ï‚· Current Medications: 
ï‚· Allergies: 
ï‚· Reproductive Hx: 
ROS: 
ï‚· GENERAL: 
ï‚· HEENT: 
ï‚· SKIN: 
ï‚· CARDIOVASCULAR: 
ï‚· RESPIRATORY: 
ï‚· GASTROINTESTINAL: 
ï‚· GENITOURINARY: 
ï‚· NEUROLOGICAL: 
ï‚· MUSCULOSKELETAL: 
ï‚· HEMATOLOGIC: 
ï‚· LYMPHATICS: 
ï‚· ENDOCRINOLOGIC: 
Physical exam: if applicable
Diagnostic results:

 

 

© 2021 Walden University Page 3 of 3
Assessment
Mental Status Examination: 
Differential Diagnoses: 
Case Formulation and Treatment Plan: 
Reflections:

 

References 

 

 

 

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