Template assignment

instructions with template to be used linked below.General Instructions:

You will have two initial psychiatric evaluations, in this unit and unit 7. These should be on separate days with two separate disorders. Complete these on different types of case studies, for example, one a mood disorder, the other a thought disorder or anxiety disorder. This section should be thorough and complete. Use the psychiatric template, as well as the examples for mental status descriptive terminology, both of which are listed below. No check box charting/documentation is permitted. Use red font if your plan of treatment differs from the preceptor according to evidence-based treatment.

Purpose:

The purpose of initial comprehensive psychiatric evaluations (IEs) is to educate you in identifying and applying diagnostic and statistical manual of mental disorders (DSM-5-TR criteria) for diagnosing and applying an evidence-based treatment plan according to the patients assessment and information. You will assess and evaluate patients in the clinical setting by identifying pertinent data, organizing it, and writing succinct psychiatric evaluations. This evaluation should be similar to the psychiatrists evaluation documentation with precise psychiatric advanced practice nursing language, succinct and technical, not narrative writing except in the history of presenting mental illness/s. You are to provide facts not opinions. PMHNPs should document the rationale of the recommended treatment in the final section called treatment plan of care, which includes the biopsychosocial formulation. It should include information to support the diagnosis, treatment, management, and recommendations based on the data presented and client preference. It is common to have some of the HPI information repeated in the biopsychosocial section and treatment plan.

Treatment Plan of Care Section:

This includes psychopharmacology and non-psychopharmacology (psychotherapy you would recommend and why according to the evidence-based treatment, use references) which you learned earlier in the program that builds on creating a succinct and accurate psychiatric mental health advanced practice nurses clinical practice. This includes illustrating health promotion recommendations, psychiatric treatment recommendations, management, and analyzing differential diagnosis possibilities.

Include health promotion, age-appropriate recommendations, medications chosen with rationale for choice if there was a discussion of contraindications, potential medical interactions or if the patient has past negative responses. Include at least one psychosocial and/or therapeutic interventions (non-medications) (i.e. psychotherapy, CAM, etc….) with rationale that are supportive of the patient. The treatment plan should not be more than two pages (if single-spaced).

Reminder: For HIPAA compliance, you are required to conceal any personal information.

Note: Download the Adult/Older Adult Initial Comprehensive Psychiatric Evaluation (CPE) Template found below. Complete the evaluation and then submit your completed psychiatric evaluation to the assignment folder. No check box charting/documentation is permitted. Use red font if your plan of treatment differs from the preceptor according to evidence based treatment.

Resources:

• Further instructions on how to complete a mental status examination: Voss, R. M., & M Das, J. (2022). Mental status examination. In StatPearls. StatPearls Publishing.