Comprehensive Psychiatric Evaluation Note Template Discussion Paper

Comprehensive Psychiatric Evaluation Note Template Discussion Paper

FAMILY ASSESSMENT

Assessment is as essential to family therapy as it is to individual therapy. Although families often present with one person identified as the “problem,” the assessment process will help you better understand family roles and determine whether the identified problem client is in fact the root of the family’s issues.

RESOURCES

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources. Comprehensive Psychiatric Evaluation Note Template Discussion Paper

WEEKLY RESOURCES

Required Readings

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disordersLinks to an external site.(5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url=https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787
Goldenberg, I., Stanton, M., & Goldenberg, H. (2017). Family therapy: An overview (9^th) Cengage Learning.
- Chapter 2, “Family Development: Continuity and Change”
- Chapter 8, “Transgenerational Models”
Therapist Aid. (2012–2020). Genograms for psychotherapy.Links to an external site.https://www.therapistaid.com/therapy-guide/genograms
Therapist Aid LLC. (© 2012-2020). Genograms for psychotherapy. https://www.therapistaid.com/therapy-guide/genograms
Document: Comprehensive Psychiatric Evaluation Note TemplateDownload Comprehensive Psychiatric Evaluation Note Template
Document: Comprehensive Psychiatric Evaluation Note ExemplarDownload Comprehensive Psychiatric Evaluation Note Exemplar Comprehensive Psychiatric Evaluation Note Template Discussion Paper

Optional Resource

Kaplin, D. (2021, Nov. 5). Family systems therapyLinks to an external site.[Video]. YouTube. https://www.youtube.com/watch?v=UVPENypTc4k

Required Media

Gehart, D. R. (2013, August 29). Progress noteLinks to an external site.[Video]. YouTube. https://www.youtube.com/watch?v=CEB1vBObUqc
Masterswork Productions. (2003). Mother and daughter: A cultural taleLinks to an external site.[Video/DVD]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/mother-and-daughter-a-cultural-tale Comprehensive Psychiatric Evaluation Note Template Discussion Paper
Sommers-Flanagan, J., & Sommers-Flanagan, R. (2013). Counseling and psychotherapy theories in context and practiceLinks to an external site.[Video]. https://waldenu.kanopy.com/video/counseling-and-psychotherapy-theories-contex
- Family Systems Therapy (starts at 4 hours)

To prepare:

Review this week’s Learning Resources and reflect on the insights they provide on family assessment. Be sure to review the resource on psychotherapy genograms.
Download the Comprehensive Psychiatric Evaluation Note Template and review the requirements of the documentation. There is also an exemplar provided with detailed guidance and examples.
View the Mother and Daughter: A Cultural Talevideo in the Learning Resources and consider how you might assess the family in the case study. Comprehensive Psychiatric Evaluation Note Template Discussion Paper

THE ASSIGNMENT

Document the following for the family in the video, using the Comprehensive Evaluation Note Template:

Chief complaint
History of present illness
Past psychiatric history
Substance use history
Family psychiatric/substance use history
Psychosocial history/Developmental history
Medical history
Review of systems (ROS)
Physical assessment (if applicable)
Mental status exam
Differential diagnosis—Include a minimum of three differential diagnoses and include how you derived each diagnosis in accordance with DSM-5-TRdiagnostic criteria
Case formulation and treatment plan
Include a psychotherapy genogram for the family Comprehensive Psychiatric Evaluation Note Template Discussion Paper

Note: For any item you are unable to address from the video, explain how you would gather this information and why it is important for diagnosis and treatment planning.

Rubric

NRNP_6645_Week2_Assignment_Rubric

NRNP_6645_Week2_Assignment_Rubric

Criteria

Ratings

Pts

This criterion is linked to a Learning OutcomeDocument the following for the family in the video, using the Comprehensive Evaluation Note Template: • Chief complaint• History of present illness• Past psychiatric history• Substance use history• Family psychiatric/substance use history• Psychosocial history/Developmental history• Medical history• Review of systems (ROS) • Physical assessment (if applicable)

20 to >17.0 pts

Excellent 90%–100%

The assignment includes an accurate, clear, and complete description of the subjective and objective information for the client family. The response addresses each of the required elements and demonstrates thoughtful consideration of the client family’s situation and culture. Comprehensive Psychiatric Evaluation Note Template Discussion Paper

17 to >15.0 pts

Good 80%–89%

The assignment includes an accurate, clear, and complete description of the subjective and objective information for the client family.

15 to >13.0 pts

Fair 70%–79%

The assignment includes a description of the subjective and objective information for the client family but is somewhat general or contains small inaccuracies.

13 to >0 pts

Poor 0%–69%

The assignment includes a description of the subjective and objective information for the client family but is vague or contains many inaccuracies. Or, several of the required elements are missing.

20 pts

This criterion is linked to a Learning Outcome• Mental status exam • Differential diagnoses—Include a minimum of three differential diagnoses and include how you derived at each diagnosis in accordance with DSM-5-TR diagnostic criteria Comprehensive Psychiatric Evaluation Note Template Discussion Paper

20 to >17.0 pts

Excellent 90%–100%

The response thoroughly and accurately documents the results of the mental status exam…. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the family in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected.

17 to >15.0 pts

Good 80%–89%

The response accurately documents the results of the mental status exam…. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the disorders selected.

15 to >13.0 pts

Fair 70%–79%

The response documents the results of the mental status exam with some vagueness or innacuracy…. Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vaguess or innacuracy.

13 to >0 pts

Poor 0%–69%

The response provides an incomplete or inaccurate description of the results of the mental status exam and/or explanation of the differential diagnoses. Or, assessment documentation is missing.

20 pts

This criterion is linked to a Learning Outcome• Case formulation• Treatment plan that includes psychotherapy interventions

25 to >22.0 pts

Excellent 90%–100%

Case formulation is thorough, thoughtful, and demonstrate critical thinking…. The assignment includes an accurate, clear, and complete treatment plan for the client family that includes psychotherapy interventions. The response demonstrates thoughtful consideration of the client family’s situation and culture.

22 to >19.0 pts

Good 80%–89%

Case formulation demonstrates critical thinking…. The assignment includes an accurate, clear, and complete treatment plan for the client family that includes psychotherapy interventions.

19 to >17.0 pts

Fair 70%–79%

Case formulation is somewhat general or does not demonstrate critical thinking…. The assignment includes a treatment plan for the client family that includes psychotherapy interventions but is somewhat general or contains small inaccuracies.

17 to >0 pts

Poor 0%–69%

The assignment provides a vague and/or inaccurate description of the case formulation and treatment plan for the client family. Or, many of the required elements are missing. Comprehensive Psychiatric Evaluation Note Template Discussion Paper

25 pts

This criterion is linked to a Learning Outcome• A psychotherapy genogram for the family

20 to >17.0 pts

Excellent 90%–100%

The assignment includes an accurate, clear, and complete genogram of the client family. Comprehensive Psychiatric Evaluation Note Template Discussion Paper The documentation style is consistent and a key is provided.

17 to >15.0 pts

Good 80%–89%

The assignment includes an accurate genogram of the client family. The documentation style is consistent and a key is provided.

15 to >13.0 pts

Fair 70%–79%

The assignment includes a genogram of the client family but is somewhat limited or contains factual inaccuracies or inconsistencies in documentation style.

13 to >0 pts

Poor 0%–69%

The genogram provided is vague or contains many inaccuracies. Or, the genogram is missing.

20 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided which delineate all required criteria.

5 to >4.0 pts

Excellent 90%–100%

Paragraphs and sentences follow writing standards for flow, continuity, and clarity…. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

4 to >3.0 pts

Good 80%–89%

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time…. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.

3 to >2.0 pts

Fair 70%–79%

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time…. Purpose, introduction, and conclusion of the assignment are vague or off topic.

2 to >0 pts

Poor 0%–69%

Paragraphs and sentences follow writing standards for flow, continuity, and clarity <60% of the time…. No purpose statement, introduction, or conclusion were provided.

5 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation

5 to >4.0 pts

Excellent 90%–100%

Uses correct grammar, spelling, and punctuation with no errors.

4 to >3.0 pts

Good 80%–89%

Contains 1 or 2 grammar, spelling, and punctuation errors. Comprehensive Psychiatric Evaluation Note Template Discussion Paper

3 to >2.0 pts

Fair 70%–79%

Contains 3 or 4 grammar, spelling, and punctuation errors.

2 to >0 pts

Poor 0%–69%

Contains many (≥5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

5 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list.

5 to >4.0 pts

Excellent 90%–100%

Uses correct APA format with no errors.

4 to >3.0 pts

Good 80%–89%

Contains 1 or 2 APA format errors.

3 to >2.0 pts

Fair 70%–79%

Contains 3 or 4 APA format errors.

2 to >0 pts

Poor 0%–69%

Contains many (≥5) APA format errors. Comprehensive Psychiatric Evaluation Note Template Discussion Paper

5 pts

Total Points: 100

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