COMPREHENSIVE PSYCHIATRIC EVALUATION NOTE AND PATIENT CASE PRESENTATION, PART 1
Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Comprehensive psychiatric evaluation notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
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.
To prepare:
- 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 disorderduring 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. All psychiatric evaluation notes must be signed by your Preceptor. When you submit your note, you should include the complete comprehensive psychiatric evaluation note as a Word document and pdf/images the completed assignment signed by your Preceptor. You must submit your note using Turnitin.
Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Grading Policy. - Then, based on your evaluation of this patient, develop a video presentation of the case. Plan your presentation using the Assignment rubric and rehearse what you plan to say. Be sure to review the Kalturasupport resources in the Classroom Support Center found by clicking on the Help
- Include at least five scholarly resources to support your assessment and diagnostic reasoning.
- Ensure that you have the appropriate lighting and equipment to record the presentation.
Readings:
- American Group Psychotherapy Association.Links to an external site. (2007–2020). Practice guidelines for group psychotherapy. https://www.agpa.org/home/practice-resources/practice-guidelines-for-group-psychotherapy
- American Psychiatric Association.Links to an external site. (2020). Clinical practice guidelines. https://psychiatryonline.org/guidelines
- Carlat, D. J. (2024). The psychiatric interview (5th ed.). Wolters Kluwer.
- Chapter 24, “Assessing Mood Disorders I: Depressive Disorders”
- Chapter 25, “Assessing Mood Disorders II: Bipolar Disorders”
- MeditrekLinks to an external site.
https://edu.meditrek.com/Default.html
Note: Use this website to log into Meditrek to report your clinical hours and patient encounters. - National Institute for Health and Care ExcellenceLinks to an external site.
https://www.nice.org.uk/ - U.S. Department of Veterans Affairs. (2020). VA/DoD clinical practice guidelines.Links to an external site. https://www.healthquality.va.gov/
- Document: Comprehensive Psychiatric Evaluation Note Template (Word document)Download Comprehensive Psychiatric Evaluation Note Template (Word document)
- Document: Comprehensive Psychiatric Evaluation Note Exemplar (Word document)Download Comprehensive Psychiatric Evaluation Note Exemplar (Word document)
- Tutorial: Kaltura Media UploaderLinks to an external site.
