NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

NRNP/PRAC 6635 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:

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:

Objective:

Physical exam: if applicable

Diagnostic results:

Assessment:

Mental Status Examination:

Differential Diagnoses:

Reflections:

References

Psychosocial History:

Medical History:

 

· Current Medications:

· Allergies:

· Reproductive Hx:

ROS:

· GENERAL:

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Objective:

Physical exam: if applicable

Diagnostic results:

Assessment:

Mental Status Examination:

Differential Diagnoses:

Reflections:

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

Here’s a template for the Comprehensive Psychiatric Evaluation:

 

—

 

**Week: [Enter week #]**

**Assignment Title: Comprehensive Psychiatric Evaluation**

 

**Student Name** 

College of Nursing-PMHNP, Walden University

 

**NRNP 6635: Psychopathology and Diagnostic Reasoning**

**Faculty Name** 

**Assignment Due Date**

 

**Subjective:**

 

**CC (chief complaint):** 

[Patient’s chief complaint goes here]

 

**HPI (History of Present Illness):** 

[Detailed description of current symptoms, onset, duration, exacerbating or alleviating factors, etc.]

 

**Past Psychiatric History:** 

– **General Statement:** [Brief overview of past psychiatric history]

– **Caregivers (if applicable):** [Information about caregivers and their involvement]

– **Hospitalizations:** [Any previous psychiatric hospitalizations]

– **Medication trials:** [List of medications tried in the past]

– **Psychotherapy or Previous Psychiatric Diagnosis:** [Details about past psychotherapy and psychiatric diagnoses]

 

**Substance Current Use and History:** 

[Description of current substance use and relevant history]

 

**Family Psychiatric/Substance Use History:** 

[Information about family members’ psychiatric and substance use history]

 

**Psychosocial History:** 

[Details about the patient’s social, occupational, and educational background]

 

**Medical History:** 

– **Current Medications:** [List of current medications]

– **Allergies:** [Any known allergies]

– **Reproductive Hx:** [Relevant reproductive history]

 

**ROS (Review of Systems):** 

– **GENERAL:** [General health-related symptoms]

– **HEENT:** [Head, Eyes, Ears, Nose, Throat]

– **SKIN:** [Skin-related symptoms]

– **CARDIOVASCULAR:** [Cardiovascular symptoms]

– **RESPIRATORY:** [Respiratory symptoms]

– **GASTROINTESTINAL:** [Gastrointestinal symptoms]

– **GENITOURINARY:** [Genitourinary symptoms]

– **NEUROLOGICAL:** [Neurological symptoms]

– **MUSCULOSKELETAL:** [Musculoskeletal symptoms]

– **HEMATOLOGIC:** [Hematologic symptoms]

– **LYMPHATICS:** [Lymphatic symptoms]

– **ENDOCRINOLOGIC:** [Endocrinologic symptoms]

 

**Objective:**

 

**Physical exam:**

[Description of physical examination findings if applicable]

 

**Diagnostic results:**

[Summary of relevant diagnostic test results]

 

**Assessment:**

 

**Mental Status Examination:**

[Detailed assessment of the patient’s mental status]

 

**Differential Diagnoses:**

[List of potential diagnoses based on the assessment]

 

**Reflections:**

[Reflections on the assessment process, potential challenges, insights, etc.]

 

**References Psychosocial History:**

 

**Medical History:**

– **Current Medications:** [List of current medications]

– **Allergies:** [Any known allergies]

– **Reproductive Hx:** [Relevant reproductive history]

 

**ROS:**

– **GENERAL:** [General health-related symptoms]

– **HEENT:** [Head, Eyes, Ears, Nose, Throat]

– **SKIN:** [Skin-related symptoms]

– **CARDIOVASCULAR:** [Cardiovascular symptoms]

– **RESPIRATORY:** [Respiratory symptoms]

– **GASTROINTESTINAL:** [Gastrointestinal symptoms]

– **GENITOURINARY:** [Genitourinary symptoms]

– **NEUROLOGICAL:** [Neurological symptoms]

– **MUSCULOSKELETAL:** [Musculoskeletal symptoms]

– **HEMATOLOGIC:** [Hematologic symptoms]

– **LYMPHATICS:** [Lymphatic symptoms]

– **ENDOCRINOLOGIC:** [Endocrinologic symptoms]

 

**Objective:**

 

**Physical exam:**

[Description of physical examination findings if applicable]

 

**Diagnostic results:**

[Summary of relevant diagnostic test results]

 

**Assessment:**

 

**Mental Status Examination:** 

[Detailed assessment of the patient’s mental status]

 

**Differential Diagnoses:** 

[List of potential diagnoses based on the assessment]

 

**Reflections:** 

[Reflections on the assessment process, potential challenges, insights, etc.]

 

—

 

You can fill in the specific details for each section based on the patient’s case.

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