Psychiatric Evaluation (AKA Psychiatric History and Physical)

Each student will complete three (3) Psych Evals. Psych Evals are to be posted to the DB in a Copy & Paste fashion for ease of reading and reference. Please do not post a link to the document. These Psych Evals will stimulate discussion, questions, and critique by peers and instructors. Psych Evals are to be posted in weeks 3, 7, and 11. These are in addition to your case presentations. Discussion including at least one meaningful response to at least one of your peers’ Psych Evals should occur in weeks 4, 8, and 12 . A meaningful response is one that demonstrates critical thought. Refer to the Carlat, Zuckerman, and Kaplan & Sadock (Ch. 5) texts for assistance. Posts that are perfunctory or only minimally meeting all grading criteria do not necessarily qualify as “excellent” which would yield full points (100). This is true for both the initial post and the response post. One response post is considered to minimally meet criteria.

The evaluation is to be read by the clinical preceptor and INITIALED for accuracy. Please include additional information in italics, for instance what you may have done differently than your preceptor, or in addition to what was actually done. This should be an evaluation that is actually done by you. The initialed evaluation is to be submitted to the course instructor for verification via email in addition to posting to the DB.

Purpose: The psychiatric evaluation is designed to gather necessary information to assess the client’s condition as well as to begin establishing a therapeutic advanced practice psychiatric mental health nurse – client relationship. The information gathered during this process will allow the advanced practice psychiatric mental health nurse to develop a diagnosis from which a precise treatment plan is prescribed. Format should be in the H & P format outlined below. Grading rubric is also below.

H & P FORMAT: (Note: This example is not exhaustive and yours must include additional data such as elaboration of rationale, neurobiology, or other information important for an academic exercise but not necessarily appropriate for a clinical document in practice. Information found below under headings can be used as prompts but are not meant to be all inclusive of information needed.)

DEMOGRAPHIC INFORMATION

IDENTIFYING INFORMATION: The patient is a (age, marital, ethnicity, gender) who presents today for a psychiatric eval (reason/referral). Sources of information for this evaluation include pt report, collateral info from.., available old records. The patient was/was not able to give an account of his/her activities/life events/symptoms in a chronological order.

SUBJECTIVE DATA

CC:

HISTORY OF PRESENT ILLNESS: (SUBJECTIVE). 

Should use the OLDCARTS acronym when trying to elicit characteristics of symptoms.

Remember to include pertinent negatives.

HPI MUST contain validation of diagnoses. Include your pertinent review of systems (ROS) here. You do not need to do an exhaustive review, only what is pertinent to the patient’s CC. Frequent symptoms that are reviewed in a psych eval are constitutional, neurological.  Remember that the ROS is SUBJECTIVE. This is not the place for assessment findings ie. Lungs clear, BS present all 4 quad, skin is clear, appears to be responding to internal stimuli, etc…

PAST PSYCHIATRIC HISTORY:

Be sure to include previous treatment, response to treatment, and explore the seriousness and context of self harm or suicide attempts. Ask about hospitalizations or partial hospitalizations. If they have been diagnosed with psychiatric illness before, ask what type of provider made the diagnosis and why. This helps you understand the patient’s insight and understanding.

            Psychotherapy

            Hospitalizations

            Suicide attempts

PREVIOUS PSYCHIATRIC MEDICATIONS:  Question carefully about length of trials, dose, why d/c

CURRENT MEDICATIONS: 

SUBSTANCE USE/ ADDICTIVE BEHAVIORS:  If + is a higher risk for suicide. First use and circumstances surrounding use, consequences of use (social, legal, economic, relational, health), last use, pattern, CAGE- Cut down-Annoy-Guilt-Eyeopener. Detox/Rehab? How do they handle stress? How often is use, how much, what is the most you did in one day? Be wary of denial/minimization. Any withdrawal S&S? Ask specifically about classes of drugs , illicit and/or prescribed (marijuana, ETOH, stimulants like cocaine, meth, or Ritalin, opiates, synthetics, bath salts, designer drugs, and non controlled like gabapentin, Seroquel, or artane), nicotine, or caffeine (also comes in pill form) and route (“have you ever snorted anything? Injected anything? Taken pills that were not prescribed to you or taken your prescription other than as directed?” Routes include insufflation (snorting) IV, oral, sublingual, transdermal, anal, or vaginal).

Inquire about eating, spending, gaming, gambling patterns. May also begin to inquire about sexual habits.

FAMILY PSYCHIATRIC HISTORY:   

            Completed suicides

            Good response to meds? If yes, which ones?

            Dx by psych or self diagnosed?

MEDICAL HISTORY:  Head injury, seizures, EEG, CT scan, review of pertinent labs, Current Medical Problems, chronic illnesses (lupus, fibromyalgia, arthritis, parkinsons, thyroid issues, cardiac disease, HTN, diabetes, cancer) any meds that have caused s&s? New onset of illness that causes stress? Last period, pregnancy test? Eating disorders? Sexual history

            Medical Illnesses

            History of Med Illness

            Surgical history

            Allergies

PSYCHOSOCIAL:  

Ability to work and love. (work=ability to structure daily activities, meet expectations, relate adequately to peers and supervisors, take on level of responsibility. Long term relationship=ability to attend to others needs, control impulses, make a commitment.)

Childhood/developmental history, family of origin, siblings, birth order, relational status, marital status-how long, children, housing situation, education, employment, abuse, religious/spiritual beliefs, legal(consider antisocial or substance abuse if extensive)

            Born and raised where/by whom/siblings/relationship status

            Education/performance

            Living situation

            Marriage/relationships

            Children

            Employment

            Legal

            Abuse

ASSETS/STRESSORS:

OBJECTIVE DATA

MENTAL STATUS EXAM: (OBJECTIVE).

Must be in narrative form.

Include all elements and be as descriptive as possible. Please refer to Kaplan and Sadock text, Ch. 5, pgs. 201-205 and the Carlat or Robinson texts.

Mental Status Exam Elements- All Borderline Subjects Are Tough Troubled Characters

A- Appearance

Height, build, hair color, style, facial hair, body modifications, facial features, scars, grooming, hygiene, odors, clothing, make-up, impression of general appearance and memorable aspects.

B- Behavior

            Attitude

            Motor activity

S- Speech

            General quality

            Fluency

            Amount

            Rate

            Tone

            Volume

            Prosody

            Spontaneity or Latency

A- Affect

            Qualities of Affect

                        Stability

                        Appropriateness

                        Range

                        Intensity

            Mood as defined by patient. Usually in quotation marks

T- Thought process    

            Flow and processing of thought. Examples:

                        Circumstantiality

                        Clang associations

                        Fight of ideas

                        Perseveration

                        Thought blocking

T- Thought content

Suicidal ideation (SI), Homicidal ideation (HI), Violent ideation (VI). If + comment on intent, plan, and    preparation

            Psychotic ideation or perceptual disturbances. Examples:

                        Delusions or hallucinations

                        Obsessional thoughts

                        Compulsions

                        Ideas of reference

                        Paranoia (suspiciousness)

                        Significant themes related to diagnosis

C- Cognitive exam – consider educational attainment when interpreting results.

            Alertness

            Orientation

            Concentration

            Memory (long and short term)

            Calculation

            Fund of knowledge

            Abstract reasoning

            Insight

            Judgment

PHYSICAL EXAM: (VS, HT, WT, LABWORK AND OTHER DIAGNOSTICS)

This section will vary in scope dependent on the setting.

DIFFERENTIAL:

DIAGNOSTIC IMPRESSION WITH FORMULATION:

RISK ASSESSMENT:

RECOMMENDATIONS AND PLAN WITH GOALS AND RATIONALES WITH NEUROBIOLOGY:

When providing treatment recommendations, be as holistic and comprehensive as possible. When describing rationales for these recommendations be as specific as possible. It is not sufficient to explain that a treatment is FDA indicated and then to outline the mechanism of action of the drug. Explain why you (or your preceptor) chose a particular drug or treatment in lieu of another. For instance, why escitalopram instead of citalopram or fluoxetine, or sertraline, etc…?

Remember to include all information that was actually done but also include, in italics, other or additional actions you would have taken or things you would have done differently.

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