recent anger outbursts seem best explained H e a l t h M e d i c a l
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.
- 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 disorder during 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, and each page must be initialed by your Preceptor. When you submit your note, you should include the complete comprehensive psychiatric evaluation note as a Word document and pdf/images of each page that is initialed and signed by your Preceptor. You must submit your note using SafeAssign.
- CASE STUDY: SY is a 16 years old Asian American female, seen along with her parents via telehealth for psychotherapy session. Patient presenting with history of depression, anxiety, and history of self harm. SY reports having a hard time since age 12 with SI first reported at age 14. Patient mother reports declining grades in school. SY reports depressive symptoms of sadness, hopelessness, feeling of excessive guilt, and thought of death. Patient also reports anxiety symptoms of irritability, uncontrollably worry. Patient also reports symptoms consistent with a trauma and stressor-related disorder due to nightmares, flashbacks, and intrusive thought related to past physical abuse by father. Therapist stated to SY parents that recent anger outbursts seem best explained by mood and traumatic stress rather than ODD since no prior history of oppositional behavior was reported. SY would benefit from outpatient treatment to reduce and manage her symptoms. A psychiatric evaluation is also recommended. SY and family will be followed up weekly for 8 weeks