A Comprehensive Psychiatric Evaluation

Week 5: A Comprehensive Psychiatric Evaluation 
 
 
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6635: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date
 
 
 
 
 
 
 
 
 
 
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
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: 

Physical exam: if applicable
Diagnostic results: 
Assessment
Mental Status Examination: 
Differential Diagnoses: 
Reflections:
References
 
Down is explanation
 
 
 
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar
 (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.) 
CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patientâ€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 patientâ€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. This section contains the symptoms that is bringing the patient into your office. 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 patientâ€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 wouldnâ€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 readerâ€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 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?
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 patientâ€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 preceptorâ€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. 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 preceptorâ€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
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.
 
 
CASE: 
A 51 years old White female who called the clinic today having low moods. She says is taking Zoloft 200mg Qday In the morning for panic attacks and PTSD and trazadone 100mg q/day at night for depression, insomnia but the last two days has been a nightmare to her.She couldnâ€t sleep at all due to flash backs. Her daughter and grand son who lives with her went out of town two days ago and she was okay but now everything started, she cant sleep because of nightmares, and flash back and even she is scared to sleep because of the nightmares and flashbacks.
She has HX of : Panic attacks, Anxiety, Depression and PTSD. Also she has HTN takes 100 mg Q day metoprol tartrate, and High cholesterol takes 40mg Q day. She exercises with her daughter 3 times a week . And has no issues with Wt. She has NO HX substance abuse and is a non-smoker. She was born and raised in Mary Land with all her cousins. Her cousins later moved to Boston. Her only sister died in a car when she was 17 years .She was the only simbling she had. Was raised up by a single mom. She was raped when someone broke in their house at age 14 years, at gun point. The mom was beaten almost to unconscious during the incident. Her sister who by then was 17 years was not home. Her mom divorced when she was 2 years and she doesnâ€t know her fathers where about. Later mom died of colon cancer @ age 45. The only relatives she has is her 31 years old daughter, her grandson 9 years and 3 cousins. No other medical HX reported.
DENIES suicidal ideation or Homicidal ideation and she contracted for safety.
No food, meds environment allergies. 
She has never been married but once in a while talks with the father her daughter who is now 31 years and grand daughter 9 years old. Her daughter is separated with her husband and after separating , came to live with her.
She denies, fever, chills, wt gain. Visual loss, hearing loss, or sore throat and runny nose. She denies SOB, Cough, Abdominal pains, Burning on urination, order or urgency. SHE denies, headaches, Denies numbness or syncope. Denies change in bladder or bowels. Denies Muscle, back or join pains or stiffness. Denies anemia or bleeding. Denies enlarged nodes or splenectomy. Denies cold or heat intolerance or polyuria
She is Alert and oriented, her hair is unkempt, appears anxious, not able to stand still but able to express self, her perception is interrupted by the flash backs. Her voice is very uneven , goes from very loud to very low. Appears to be very drained and tired
She has been seeing the psychotherapy for 3 moths. She used to go to group therapy when she was in her 30`s but stopped because she felt like it was not helping any more. She has been using grounding therapy which has helped for a long time with the flash backs but last two days is not working.
PLAN: To change her grounding techniques to:- touching her best pillow to orient her of where she is, putting her favorite picture in her bedroom to see it, to have a fragment smell different from what she was wearing the day of the rape. To write down in a journal all these week and if became suicidal call immediately.
 
 
 
 
 
BELOW IS AN EXAMPLE FROM A FRIEND
 
Comprehensive Psychiatric Evaluation Note and Patient Case Presentation
 
 
JMMMM
College of Nursing-PMHNP, Walden University
NRNP 6645: Psychotherapy with Multiple Modalities Practicum
Dr. Loraine Fleming
March 29, 2021
 
 
 
 
 
 
 
 
 
 
 
 
Subjective:
CC (chief complaint): “I need to get my life back on track”
HPI: WL in a 61-year-old African American male who presents for psychiatric evaluation of feelings of depression. He is not currently prescribed medication for depression. He has multiple physical and psychiatric comorbidities and is currently in a wheelchair. The patient is the main caregiver of his ailing wife and has begun to have difficulty managing stress related to his own declining health. He reports feelings of hopelessness at times but denies any suicidal thoughts. He reports dealing with depression since 1984 but is not currently being treated. He has current substance use issues and is in a suboxone program. He reports “messing up” at times causing his depression to worsen. He was referred for treatment by his primary care provider.
Past Psychiatric History: 
• General Statement: WL entered psychiatric treatment for depression at the age of 25. He has had treatment on and off since that time. He entered substance abuse treatment in 2015 after beconing addictedto cocaine, heroin, opiates, and benxodiazapines. He is currently receiving suboxone treatment for substance abuse disorder.
• Caregivers (if applicable): WL is independent although he is in a wheelchair.
• Hospitalizations: Wl reports an inpatient hospital stay in the early 2000 when he had a knee replacement. He reports 4 hospital stays for the fracture of his left foot due to an accident.
• Medication trials: WL is not able to report any medication failures. He reports he has not taken medication for depression in over six years.
• Psychotherapy or Previous Psychiatric Diagnosis: WL entered individual and group psychotherapy in 2015. He reports the therapy has been helpful and he will continue to attend sessions. 
Substance Current Use and History: WL has a history of abusing cocaine, last use three weeks ago, Heroin, last use over a year ago. Klonopin, last use was three weeks ago. Xanax, last use unclear but he reports it has been a long time. Opioids, last use over a month ago. Cannibis last use several years ago. Nicotine, last use today.
Family Psychiatric/Substance Use History: Pt reports both his mother and father were alcoholics. No other familial psych or substance use history reported.
Psychosocial History: WL is a 61-year-old male who has been married for 37 years. He and his wife live in a single family home. He reports the marriage is sometimes good but he argues with his wife a lot. He continues to be independent but is in a wheelchair due to an accident that resulted in three different fractures to this left ankle. His wife has had recent medical issues and he reports having to care for her due to her inability to ambulate well and complete ADLâ€s. WL and his wife have two daughters ages 46 and 43 and two sons ages 38 and 39. He is the third child of four children having two older brothers and one younger sister. WL reports not knowing if his siblings are still living as he has no contact with them. WL was raised by his paternal grandmother from the age of 9. He was taken from his mothers custody when he was two months old and raised by is father until he was 9 years old and his father died. H reports his mother died but he does not know the details. He has a 10th grade education. WL worked as a heating and air conditioner technician for 20 years until he retired. He does not currently work. He does not drive but is able to take public transportation. He endorses no issues having access to healthcare.
Medical History: 
 
• Current Medications: 
1. AmLODIPine Besylate 5 MG Oral Tablet, 1 by mouth daily for Essential (primary) hypertension
2. Suboxone 8-2 MG Sublingual Film, 1/2 strip SL tid, for Opioid dependence, uncomplicated
3. CloNIDine HCl 0.1 MG Oral Tablet, 0.1mg by mouth bid prn sbp >160; cloNIDine HCl 0.2 MG Oral Tablet, Take 1 tablet (0.2 mg) by mouth 3 times per day; CloNIDine HCl 0.3 MG/24HR Transdermal Patch Weekly, 1 patch topically qweek for Essential (primary) hypertension
4. Ibuprofen 800 MG Oral Tablet, 800mg po tid prn for Chronic pain due to trauma
5. MetFORMIN HCl 1000 MG Oral Tablet, 1000mg by mouth bid for Type 2 diabetes mellitus without complications
6. Lyrica 150 MG Oral Capsule, 150mg by mouth bid for neuropothy associated with Type 2 diabetes.
7. Januvia 100 MG Oral Tablet, 100mg by mouth qday, for Type 2 diabetes mellitus without complications.
• Allergies: NKDA
• Reproductive Hx: WL states he is sexually active with minimal age-related issues.
• ROS: (Completed by physician)
CONST: no fever or chills, no weight loss
C/V: pt denies CP, palpitations, LE edema
RESP: pt denies SOB, wheezing, hemoptysis
GI: pt denies N/V/D, no heartburn or bowel changes
INTEG: pt denies rash, itching, or skin changes
NEURO: pt denies HAs, vision changes, dizziness.
Objective:
Diagnostic results:
No diagnostics performed. (see plan for future diagnostics)
Assessment:
Mental Status Examination: 
WL is a 61-year-old African American male who looks his stated age. He is discheveled but dressed appropriately for the weather. There is no evidence of abnormal motor activity although he is in a wheelchair. His speech is of normal speed and volume and he communicates clearly. His thought process is logical and goal-oriented. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect is congruent to his mood. His facial expressions and body language are appropriate for the content and situation. There is no evidence of hallucination or delusional thinking. He denies any suicidal or homicidal thoughts. He is oriented x4 with recent and remote memory intact. He has good concentration. He appears to have poor judgement but good insight.
Differential Diagnoses: 
 
1. Persistent Depressive Disorder (Dysthymia)
WL meets the criteria listed in the DSM-5 as evidenced by fatigue and feelings of hopelessness for most of the day, more days than not for the past two years (American Psychiatric Association, 2013). He has not been without symptoms for more than two months over the past two years and there has not been a manic or hypomanic episode during this time (American Psychiatric Association, 2013).The symptoms cause significant stress in important areas of functioning (American Psychiatric Association, 2013).
 
 
2. Major depressive disorder, recurrent severe
WL has met criteria in the past and has had a previous diagnosis of MDD. He does meet all criteria from B-E but MDD is ruled out due to meeting two of the nine criteria listed in the DSM-5 . For this diagnosis he must meet at least five (American Psychiatric Association, 2013).
 
3. Substance/medication-induced depressive disorder: 
According to the DSM-5 a substance/medication-induced depressive or bipolar and related disorder is distinguished from persistent depressive disorder when a substance is judged to be etiologically related to the mood disturbance (American Psychiatric Association, 2013). Although WL does have a substance abuse disorder, he has suffered from depression in the past prior to the substance use. This diagnosis is ruled out due to the past episodes of depression.
Reflections:
WL has been coming to the clinic since 2015. He was previously diagnosed with MDD and GAD. However, he is no longer prescribed medications to treat either diagnosis. He has had some success in the substance abuse program, however, I believe he should continue to be treated for psychiatric issues as well. There is a correlation between psychiatric issues and substance use. If both problems are treated simultaneously he will have a better chance at success. 
Literature seems to suggest, disparities are present in all facets of the disease – in risk factors, presentation of disease, type and severity of symptoms, and modalities of care offered (Baily et al., 2019). A legal/thical consideration in psychiatric treatment of depression is understanding the differences in individuals that require different approaches. Research shows the criteria to diagnose depression neglects essential experiences of persons in depressive episodes (Data on Depression, 2021). The approach to diagnosis and treatment must be more individualized . Chisholm et al. (2016) discusses how the current treatment of those with lower socioechonimical background is less successful in terms of life-years gained. 
WL began treatment at age 25. However, he has not concistently remained in treatment. According to past history and patient reports, he has stopped treatment several times and had begun self-medicating with illicit drugs which led to an addiction problem. Depression among African Americans often goes untreated due to the population not seeking treatment. Studies have shown a correlation in socioeconimical position and depression among the African American population (Baily et al., 2019). Other ethnic factors impacting the prevalence of depression include the educational level and martial status of individuals (Baily et al., 2019). Disease prevention programs for depression and other mental health issues should be targeted toward ethnic groups with lower socioechonomic status in order to provide education and treatment with those facing disparities.
Case Formulation and Treatment Plan:  .
Initiate interpersonal psychodynamic psychotherapy group sessions. Patient and therapist will meet individually prior to the beginning of the first group to establish goals for therapy. Group will meet for 90 minutes each week on Wednesday from 9 oâ€clock a.m. through 10:30 a.m.
Patient is instructed to complete a journal throughout the week regarding emotional issues and feelings that derive from the issues noted.
Retrieve and review hospital records/therapist records for collaborative information.
Refer WL to a psychiatrist for medication management for possible Persistent Depressive 
Disorder, Major Depressive Disorder, and Substance Use Disorder.
Discuss the benefits of psychopharmacological therapy.
Discuss current medication regimen.
Discuss substance use history and any current use.
Screening for depression (i.e. Hamilton Depression Rating Scale (HDRS), Beck Depression
Inventory (BDI))
Complete a psychological evaluation.
Complete a suicide risk evaluation.
Lab tests such as Vit D, TSH, HGB, A1c, LFT to rule out physiological issues that may cause
symptoms.
Follow-up with PCP for continued medical management of left ankle fracture. Encourage patient to talk with PCP regarding physical therapy referral and home health assistance resources for his wife.
Return to clinic: Tuesday at 0900 prior to the first group session for individual goal-setting conference.
Plan discussed with patient. Patient was given the opportunity to ask questions and provide input for plan formulation. Patient was provided support was able to voice needs. Patient is agreeable to plan and states he will follow treatment regimen as discussed. 
Client has emergency numbers: Emergency Services 911, the RAFA Crisis Line 1-800-xxxx. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal.
 
 
 
 
 
 
 
 
 
 
 
 
 
References 
American Psychiatric Association. (2013). Depressive Disorders. In Diagnostic and statistical manual of mental disorders (5th ed.) Arlington, VA: Author. https://doi-org.ezp.waldenulibrary.org/10.1176/appi.books.9780890425596.dsm04
Bailey, R. K., Mokonogho, J., & Kumar, A. (2019). Racial and ethnic differences in depression: current perspectives. Neuropsychiatric disease and treatment, 15, 603–609. https://doi.org/10.2147/NDT.S128584
Brijnath, B., & Antoniades, J. (2018). Beyond patient culture: filtering cultural presentations of depression through structural terms. Critical Public Health, 28(2), 237–247. https://doi-org.ezp.waldenulibrary.org/10.1080/09581596.2017.1344771
Chisholm, D., Sweeny, K., Sheehan, P., Rasmussen, B., Smit, F., Cuijpers, P., & Saxena, S. (2016). Scaling-up treatment of depression and anxiety: a global return on investment analysis. The Lancet, Psychiatry 3(5), pp 415-424. DOI:https://doi.org/10.1016/S2215-0366(16)30024-4
Data on Depression Reported by Researchers at University of Colorado (Questionable agreement: the experience of depression and DSM-5 major depressive disorder criteria). (2021). Mental Health Weekly Digest, 120. https://link.gale.com/apps/doc/A651748889/EAIM?u=minn4020&sid=EAIM&xid=aa720e
 
 
 
RUBRICS
 
Description of chief complaint and history of present illness
5 (5%) – 5 (5%)
The student provides an accurate, clear, and complete description of the chief complaint and history of present illness.
4 (4%) – 4 (4%)
The student provides an accurate description of the chief complaint and history of present illness.
2 (2%) – 3 (3%)
The student provides a vague, inaccurate, or incomplete description of the chief complaint and history of present illness, or description is missing.
0 (0%) – 1 (1%)
The student provides a completely inaccurate, or incomplete description of the chief complaint and history of present illness, or the description is missing.
Description of past psychiatric, substance use, medical, social, and family history
5 (5%) – 5 (5%)
The student provides an accurate, clear, and complete description of past psychiatric, substance use, medical, social, and family history.
4 (4%) – 4 (4%)
The student provides an accurate description of past psychiatric, substance use, medical, social, and family history.
2 (2%) – 3 (3%)
The student provides a vague, inaccurate, or incomplete description of psychiatric, substance use, medical, social, and family history, or description is missing.
0 (0%) – 1 (1%)
The student provides a completely inaccurate, or incomplete description of psychiatric, substance use, medical, social, and family history, or description is missing.
Discussion of most recent mental status exam and observations made during interview and review of systems
14 (14%) – 15 (15%)
The student provides an accurate, clear, and complete discussion of results from most recent mental status exam and observations made during interview and review of systems.
12 (12%) – 13 (13%)
The student provides an accurate discussion of results from most recent mental status exam and observations made during interview and review of systems.
11 (11%) – 11 (11%)
The student provides a vague, inaccurate, or incomplete discussion of results from most recent mental status exam and observations made during interview and review of systems.
0 (0%) – 10 (10%)
All or most of the discussion is inaccurate or missing.
Discussion of diagnostics with results
9 (9%) – 10 (10%)
The student provides an accurate, clear, and complete discussion of diagnostics with results.
8 (8%) – 8 (8%)
The student provides an accurate discussion of diagnostics with results.
7 (7%) – 7 (7%)
The student provides a vague, inaccurate, or incomplete discussion of diagnostics with results.
0 (0%) – 6 (6%)
All or most of the discussion is inaccurate or missing.
Diagnosis with three (3) differentials
23 (23%) – 25 (25%)
The student provides an accurate, clear, and complete diagnosis with three (3) differentials.
20 (20%) – 22 (22%)
The student provides an accurate diagnosis with three (3) differentials.
18 (18%) – 19 (19%)
The student provides a vague, inaccurate, less than 3 or incomplete diagnosis with differentials.
0 (0%) – 17 (17%)
All or most of the discussion is inaccurate or missing. Less than 2 diagnosis.
Comprehensive Psychiatric Evaluation documentation
23 (23%) – 25 (25%)
The response clearly, accurately, and thoroughly follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.
20 (20%) – 22 (22%)
The response accurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.
18 (18%) – 19 (19%)
The response follows the Comprehensive Psychiatric Evaluation format to document the selected patient case, with some vagueness and inaccuracy.
0 (0%) – 17 (17%)
The response incompletely and inaccurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.
 
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