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GONZALO BACIGALUPE When I'm asked to do a consultation, one of the first things I ask is, what will be the most benefit for the client and the therapist and in the case that you're going to see I'm basically asked to have a reflecting team and what we did was first have an interview with the therapist and the family and ask them what they will find useful for the interview and basically to ask them about the history of the therapy and the history of what are the kinds of things that they have been working on. I ask the reflecting team to come in and I instructed them to think of themselves as so let the god mothers of the therapist, who in a way, put them, himself, or in this case herself at risk in front of her peers and another people. So, I wanted them, the reflecting team to address the therapeutic system as a whole not just to address the family, I wanted them to talk also about the therapist and to be protective of them. I also ask the reflecting team not to be too much of clinician, but to really react on a more personal level around the family. I sometimes reflected on what they were saying to clarify or to expand the idea or how I understood it to give voice to other possibilities, but respecting the personal peace, and then, I ask I ask the family to come back to, in a classical way, to respond to those comments what strike them. In the case that we watch, it seems that the family was dealing with sort of like two forms of trauma and/or three forms of trauma; one is, history of battering the domestic violence, child sexual abuse, a history of immigration that in some ways we lay it to that trauma getting away from it and basically the mother of five children deciding that they need to move out of the home, but in the process leaving one behind who is later on sexually, I mean, raped by the father. And then at the present moment mother dealing with a fairly traumatic illness that have her, very disable, unable to walk and to work. So, it's sort of like the interview trying to address this different forms of trauma and the way in which the young adults are trying to make sense of their bicultural life and how the whole family is trying to make sense of being bicultural and being immigrants. The session doesn't end with a need or incredible intervention of my part because I feel that this is the part of the therapist to try to decide, this is the family that's been working this therapist for year and half. Therefore, they have a relationship I feel that I need to respect and so those are the basic intercomments. So tell me how is it that you came out with the idea of having this interview with me? 

00:04:30Sharleen 

00:04:30Patti 

00:04:30SANDI Okay. I'm going to go back when Patti came in for the first time. She came in because they were chaos at her household. 

00:04:45Sandi – their therapist 

00:04:45SANDI She came to this country twelve years ago with her four children and one was left behind, her daughter who was 10 years old at that time, eight years old at that time, was left behind. Just two years back, finally they were able to get her visa and she brought her to United States. So ever since she came here chaos was created inside the household. 

00:05:20GONZALO BACIGALUPE So I'm clear, Sharleen you are? 

00:05:25SHARLEEN Her daughter. 

00:05:25GONZALO BACIGALUPE Her daughter. And how old are you? 

00:05:25SHARLEEN I'm 23. 

00:05:25GONZALO BACIGALUPE 23, and how old are your siblings? 

00:05:30SHARLEEN 24. 

00:05:30GONZALO BACIGALUPE And that's sister or brother? 

00:05:35PATTI Sister. 

00:05:35SHARLEEN And then 21-year old sister and 18-year old brother and a 15-year old brother. 

00:05:50GONZALO BACIGALUPE Okay, and which one is the one that stayed there. 

00:05:50SHARLEEN 21. 

00:05:50SANDI 21. 

00:05:50GONZALO BACIGALUPE 21. Okay. All right. Okay. Go ahead, sorry. 

00:05:55SANDI And I met with the entire family for two couple of sessions and she really interested and wanted to be in therapy 21, so. 

00:06:10GONZALO BACIGALUPE What's her name? 

00:06:10SANDI Shireen. 

00:06:15Shireen – the 21 year old sister 

00:06:15emigrated from Iran 2 years ago 

00:06:15GONZALO BACIGALUPE Okay. 

00:06:15SANDI She just felt that she needed the money more than coming to therapy and she refused the entire time and mom tried to she ask her, if she doesn't feel comfortable with me. She said she has had all appointments with other therapists at this clinic, still she refused to come in, but they kept on seeing Patti and the oldest daughter Sheela for about a year and a half now. Ever since then, we started working on the chaos in the household, what is it that creating chaos and I found out that Patti lives with traditional ways of living, their daughters are trying to detach herself from Patti and grow on their own and find their own individuality. So would ask where they have been working on and every since then she had two surgeries. 

00:07:30Patti had surgery on both feet. 

00:07:30SANDI Every thing is started. 

00:07:35GONZALO BACIGALUPE Who had two surgeries? 

00:07:35SANDI Patti had two surgeries on her feet. 

00:07:40Surgery failed – she is disabled. 

00:07:40SANDI And that created more tension, anxiety in the family. 

00:07:50She is in constant pain. 

00:07:50SANDI So — and I have been seeing her after her surgery and she has been referred to a psychiatrist for medication because a lot of time she feels hopeless, helpless, she feels her children are out of control, she can't be in charge, they no need her anymore. So those are the major. 

00:08:20GONZALO BACIGALUPE If you were to describe an accomplishment and you have accomplishment with the therapists during this time. Is there something that you will say, it's an important accomplishment? 

00:08:35SANDI Awareness of the difference between individualist ways of living and collectivistic ways of living and awareness that how they to respect and understand the children are growing in this country and they are going to try to detach themselves from Patti to be able to grow on their own. 

00:09:00GONZALO BACIGALUPE What has been for you this work with Sandi? 

00:09:05PATTI She helped me to understand the kids grow up and left the house and they have been not to depend on them so many times and try to live my life alone and then to take care of my things, my problem in the life and respect them and give them their freedom. 

00:09:30GONZALO BACIGALUPE Do you have a sense that that is sort word that has been accomplished that is more to be done. 

00:09:35PATTI I think I need more to be done, I'm not done. No. 

00:09:40GONZALO BACIGALUPE Do you have of sense of what is that you would like to do? 

00:09:45PATTI Yeah, I'd like to learn to lead my life alone and depend on the kids a lot because in our custom when the parents get old and especially when they are in my situation they can't walk or take care of theirself, the kids are always there for parents, but over here no, they have their own life. And I expect them to be there all of the time for me and they can't, matter of fact, I had a big argument with her last night about that, I had a very bad back for few days I was done and last night, I called her and I said come and spend a night with me and she said no, I can't. I said, you should and you have to and we got into a big argument. 

00:10:30GONZALO BACIGALUPE So, you are on your own right now, you're living in your own and each of the kids have their own place or? 

00:10:35PATTI Three of them, two of the boys lived with me 18 and 15 years old, but the 15 years old was with her for three four days and I was with 18 years old a lot. I feel like they doesn't do enough for me. 

00:10:50SHARLEEN She makes her own plans for me, she expects me to like to go with her and spend time with her because she is bored. I have too much to do, I can't unwind your boredness, find something else to do, but I have plans, I'm 24 and my world around me is happening and I need to be there, I accomplish things. I can't sit down and like chitchat for a whole day. 

00:11:15PATTI And I feel I'm depressed I cannot move, I need them to come and visit me, spend a night with me. 

00:11:20SHARLEEN I spend, I — out of the seven days, I saw her for six days, I make sure, I saw her for six days out of that week. I spent a day with a friend and I got some stuff done and she felt like I owe her something because I didn't spend that time with her. And she did a nice job raising us, she was a wonderful mother, we all suffered through the good and the bad in the family like every family does, but we have all grown up, we can't stay in the nest forever. I'm trying to experience life and my own good or bad, whether you approve it or not, it's my life. 

00:11:55GONZALO BACIGALUPE Sharleen, is this something that you have had a discussion, the three of you, I mean this particular or this is not like? 

00:12:00SHARLEEN I think, I have mentioned to her, but she takes it personal, she doesn't hear me out. 

00:12:05GONZALO BACIGALUPE Is this something that you have had conversations with the family? 

00:12:10SANDI Over and over, yes. Especially with the oldest daughter Sheela, she also, being the oldest, she feels that she has been the parentified child all her life, she has played a role of a man for — in her mother's life and then the entire, I've seen her for about four times right, four, five times and she used to cry the entire time in the session. 

00:12:40GONZALO BACIGALUPE And I realize that you're being very touched by this, I mean this is not something that. 

00:12:45SHARLEEN Yeah, it's something that I strive so hard to accomplish and as soon as I feel like I got her on the right step, there she goes falling depart again asking for like, I give her what I can and she keeps on asking for more and more and that's not how my life works. 

00:13:05GONZALO BACIGALUPE What do you right now? Are you working, studying? 

00:13:05SHARLEEN Yeah, I work and I'm trying to get my license. I'm trying to get accomplish things from now. 

00:13:15GONZALO BACIGALUPE What kind of work are you are doing right now? 

00:13:15SHARLEEN I just — I find promotional jobs and then, I'm trying to get my real estate license. 

00:13:25GONZALO BACIGALUPE And your sister? 

00:13:30SHARLEEN Sheela? 

00:13:30GONZALO BACIGALUPE Sheela, is she also on her own? 

00:13:30SHARLEEN Yeah. 

00:13:30GONZALO BACIGALUPE She is also working, studying? And the 18-year old, what is he doing? 

00:13:35PATTI He is a student. 

00:13:40GONZALO BACIGALUPE In high school? 

00:13:40PATTI Yes. 

00:13:40GONZALO BACIGALUPE So, he is finishing high school right now? 

00:13:40PATTI Yes, this year. 

00:13:45GONZALO BACIGALUPE And is he talking also about leaving home after finishing the high school or what are his plans? 

00:13:50SHARLEEN He is not sure yet, depends on how the family situation is going, you know, everybody looks for happiness and peace of mind, depends like how he feels around the home. 

00:14:00GONZALO BACIGALUPE How about the 15-year old? 

00:14:00PATTI I have lots of problems with him, I don't get long with him at all. 

00:14:05SHARLEEN She has no patience. And she takes it out on other people. 

00:14:10PATTI Because I can't do anything, I walk fewer step and that's it, I have a horrible pain after fewer step. And I have to sit and wait for them to come and give me a glass of water. 

00:14:25SHARLEEN Well, the thing is I want her not to wait for us, I want her to be on her own, I want her to learn how to like, you know there is a — you know superman lost his both feet and he sits on a wheel chair, but he is still going on with life. 

00:14:40PATTI But Superman has money, somebody take care of him all of the time. 

00:14:40SHARLEEN You have to learn how to ease your own mind and not depend on other people. She is forty years old, if she was 60, poor dying lady, I would be more sympathetic, just 40 years old, there is much more for her to experience. It's not time for her to start depending on her children yet. We're only in our 20s, let me live life, let me experience and do what you can, while you can. Give it your best. 

00:15:10GONZALO BACIGALUPE Sharleen, how is that you decided to come today, I mean what's it? 

00:15:10SHARLEEN Because I was with her last week and they asked me to, they invited me to, so I thought maybe you would like help as much as this is helping you. 

00:15:20GONZALO BACIGALUPE Do you have a sense that you are sort of being representative of the other of your siblings that you are coming as a representative for all of them in some way? 

00:15:30SHARLEEN We are all trying to get her to be more positive and feel like do a little step at a day, but try your best to be better, to do a better in life. Every time I try to push her to be more independent and not as much like do that all stuff with her that she could do on her own, she keeps like she has a broken wing that she wants to buoy on us, after a while, it gets heavy. You just want it off because I want to breathe and I want to experience my life. I cannot live like a 20-year old from Iran. I have different things to experience than to sit at home. And the thing is like I don't feel like I can accomplish with her when I'm at home because she is either watching TV or on the phone, which is just like sad people around and I can't hang out like that. 

00:16:20GONZALO BACIGALUPE Besides the — your five kids and yourself, is there anybody else in the family here who immigrated with you guys or –? 

00:16:25PATTI I have a cousin, but they live LA and I don't even talk to them. 

00:16:35GONZALO BACIGALUPE And so, in a way, when you need something, basically the only thing that you feel like you can go for your kids? When you — we're talking about chaos, there have been — there were some chaos about a year and half ago when we start through the work and can you tell me little bit about what the chaos was about or what — how you define that? 

00:17:00SANDI Okay. I just want to mention something about before her surgery Patti has been a very independent women as far as working hard, single mother, raising all her children and they are all proud of her in many ways. When they came she did not have the health problem as far as the pain in her feet, constant pain and feeling hopeless and helpless. They came for a different reason was for Shireen, because Shireen came form Iran and two weeks everything was wonderful, they all re-united, they enjoyed, celebrated for two weeks, and then, she started telling him about the stories that her father abused her sexually, physically and she was abandoned in their house. So, that's where the explosion, the chaos started. Before that – 

00:18:05GONZALO BACIGALUPE When you say that the chaos started, what started to happen? 

00:18:05SANDI They were fighting, constant fighting, screaming, yelling and cursing each other. Before that, my understanding was that kind of was a very peaceful way of living, am I correct in this? 

00:18:25GONZALO BACIGALUPE Okay. All right, so the tension has really sky rocketed after Sheela came back, I mean, two weeks after one, and then, he came out of that — there's been this –? 

00:18:35PATTI As she came back, she was blaming me, why did you left me back home with my dad there, he did all of those things to me. And my husband used to tell her, you was a rotten fruit and she didn't take you, you are a rotten one. She took the good ones and left you behind for me. And she was blaming me for everything. 

00:18:55GONZALO BACIGALUPE When you left, you had separated from your husband? 

00:19:00PATTI No, we were living together my daughter had a medical problem, Sheela and matter of fact, her, and they give me a medical visa to come here and Sheela and Sharleen born here many years ago. And when I went to get a Visa, they told me two of them are American citizen, you have to take them, we cannot say no. And my boys were four years old then 18 months old and Shireen was eight and they said, they decide Shireen should be stayed home and make it sure I'll will be go back. But after I came here, my daughter didn't have any problem any more and they were find and I used to stay here and I decided to live here. And my husband was keep telling me don't come, don't come, stay there, I will come some day and he never sent me any money, he never did anything for us at all except sending the letter 10 pages every single day, what to do, how to leave and how to raise the kids and I throw them all in the trash because I didn't had a time to read them and I didn't had time to practice anything he said and I ignored everything until like six, seven years later, he just wrote a letter, I want you to be back home, you are my wife, I order you to back home and I said, forget about you, I have my life here. And who wants to go back to that life. And I was thrown all of the time to bring Shireen and I couldn't until three years ago. Finally, she came and for couple of days, weeks everything was fine until she started talking about every problem she had back home and for any little mistakes she made, my husband used to beat her up and keep her outside the house for all night and many, many things, the things he used to do to me. And I know what she talking about and what she had to go through, but I couldn't do anything about it. I didn't have the choice. When I came here few week after, few months after I was here I called my dad and I said, I'm worried about Shireen, I afraid to beat her and I'm not there to protect them because I was all this over to protect the kids. Each time he wants to beat them, I was right ahead of them and say, beat me, don't touch my kids, do whatever you want with me. And my dad said you should imagine your house was in the fire, you took four of them off the fire, you left one behind, leave her behind and take care of those four you have and I thought about it, I thought, he is very right, absolutely right, I should take care of the four I have over here. Why should I go back there. He would be — make everybody miserable. I didn't have a very good life but like she said, we all worked together and take care of each other and like I was out all of the time and like Sheela said, she was father of the kid, take care of the kids, take care of the bank account, his groceries, everything. And I used to be a care giver and save it all this and Sheela and Sharleen would stay home and take care of the kids, two younger brother and each other. And everything was okay until Shireen came. And then, after few months, for a couple of years, we had a problem until, thanks god, last May she got married with somebody behind our back. 

00:22:25GONZALO BACIGALUPE Who got married? 

00:22:25PATTI Shireen, we were on the camping three when she ran away with one of my friend's son and got married and she moved out the house and my house is so quiet and I enjoy the life so much except I get so depressed because I feel hopeless and I have so much pain and they can't do anything about my pain, I'm always in pain. 

00:22:50GONZALO BACIGALUPE As you must have seen, when — do you work on how they make sense of what happen to Shireen, I mean, in Iran during the time that she was alone, was that workout with the whole family, they were some sort of a conversation in therapy? 

00:23:05SANDI Yes, I met, as I remember, I met with all of them and they expressed their feelings and shouting, yelling, everything was going on in our session. And they were expressing, Shireen was constantly blaming the mother for all her pain and what happened to her to lead on and a mother tried to explain her situation, the sisters also, brothers also. So, we had few sessions like that. 

00:23:35GONZALO BACIGALUPE What was your sense of how it can — that there were some sort a resolution around that that people were able to make sense that Patti and the kids were able to make sense of this or? 

00:23:50SANDI I was hoping for that, that was my really aim to discover, explore their meanings of the situation and. 

00:24:00PATTI They got in fight, we couldn't keep coming back, I couldn't make them to go back as a family. 

00:24:05GONZALO BACIGALUPE Is it still something that is very hard to talk about or not? 

00:24:10PATTI About the rape you mean? 

00:24:10GONZALO BACIGALUPE Yeah? 

00:24:10PATTI What do you think? 

00:24:15SHARLEEN Well, I'm not very worried about, I mean, it's affecting her life and I feel sorry for her, but I try not to think about it. 

00:24:25GONZALO BACIGALUPE And do you have the sense that that's what anybody else in the family tries to do that tries hard so they doesn't affect? 

00:24:30SHARLEEN Because we already did our crying over it and I'm over it, I'm ready to move on about it. 

00:24:40PATTI It's like when somebody die, you grieve for it. When I heard about it, I was crying and crying and crying for months and months, and then later on, it's something you can't do any thing about this, something happened, what am I going to do about it. I tried to take her to counseling, I take her to Iranian psychologist, 200 dollars an hour. And she would then go back, then what can I do. And I think I'm over with it, I feel sorry for her, but what can I do. My older son doesn't want to talk to this, his dad, nobody wants to contact him or have any relationship or any thing to – 

00:25:20GONZALO BACIGALUPE Has he acknowledged that he did rape her? 

00:25:25PATTI I told him once, and he will start cursing at me and I hang up. I said, I pay a dollar fifty a minute, I don't want to hear your cursing. I want to see what's going on, what happened and you tell me if it happened or not and will start cursing and I hang up. And after that, I never called back, and he is remarried, he married to Iris after Shireen came, during the three years, he got married twice and he has moved on with his life. 

00:25:55GONZALO BACIGALUPE Is there any, I mean, is there a way in which you think, I mean you, Sharleen and maybe some of your siblings, but just from your perspective, is there where you think about how the relationship with your mom should be, is it — do you have a dream for how? 

00:26:15SHARLEEN Yeah, I just wanted her to be more peaceful. I want her to lower her expectations and to accept a lot of things about life. 

00:26:25GONZALO BACIGALUPE What do you mean lower expectations, what? 

00:26:25SHARLEEN Not to expect so much from people, not to — I think what she does is, she thinks of an idea and she reacts on it so so quick without she calming herself down before she like takes the reaction. 

00:26:40GONZALO BACIGALUPE Do you have a sense that your mom thinks that you can do more than what you can actually do? 

00:26:45SHARLEEN I have a sense that she is holding me back from doing all that I could be doing and as soon as I could get excited about her, every time I give her little bit of hope, there she goes back expecting more, and then, getting angry at. She has some thoughts then she is so hang up that these thoughts are like so true and she gets angry about them and she hold on to them, then she accuses people and all they are her thoughts in her mind. And I just ask her to leave them alone, let people be and everything is going to — just then it's going to take its course. 

00:27:15GONZALO BACIGALUPE Am I trying to tell you, if you were to think about how your ambition, how you see it in the future, the relation how do you see it? I mean, if you were to move in a way the direction that you want it to move, how many times do you see yourself beside in her or interacting with her? 

00:27:35SHARLEEN I speak to her every day, I mean almost everyday. 

00:27:40GONZALO BACIGALUPE But again, I'm asking you more about – 

00:27:40SHARLEEN Like in the future, yeah, I just want her to like be more calm about like life so that I could like through her better. So that when I do spend time with her that I could enjoy it better instead of her frightening my other siblings or telling me about how so and so, this and that and this and that. I just want her to be more calm so we could just enjoy the moment when we hang out, rather than like. 

00:28:05GONZALO BACIGALUPE What kinds of things do you enjoy with her in the moment? 

00:28:10SHARLEEN I try to tell her about my ideas, how she is like be more relaxed and not — you know same things. 

00:28:15GONZALO BACIGALUPE Patti, how do you ambition the relationship with your daughter? 

00:28:20PATTI I saw her on Sunday, Sunday night and Sunday night, I went to visit my older daughter and she was aware that I took the dinner for them. And after I laid down fully at my daughter, older daughter house, I couldn't get up, they pulled me and took me to the car and I came home. I didn't see her until yesterday afternoon and I said, I have been done with my bag. I just want them to spend time with me. I'm lonely, I get depressed when I'm lonely. If she had a job, if she was working like the other people, I would understand she is working everyday like my older daughter, she go to her school, she work, I understand she doesn't have a time, but I know she has time and I expect her to come and spend the time. And I said, I gave you whatever you want, whatever I have in the house like furniture, this and that, anything she said, mom can I have this? Sure, honey, doesn't matter you or me, you can have it. And when I'm like that with you, I expect you to do something for me too. 

00:29:20GONZALO BACIGALUPE Patti, I understand how also you are feeling upset about this, about and I know that the question I'm asking is hard, I mean, how do ambition the relationship with Sharleen? What will you like to happen in the future? 

00:29:40PATTI Between me and her? I want her to just spend time with me whenever she can. 

00:29:45GONZALO BACIGALUPE What kind of time for instance would you like to –? 

00:29:45PATTI She come and stay at my house because she knows I cannot live with two boys and go to her house. She most of the time ask me to come and stay at my house, but when I go to her house and I spend over there, I'm worried about 18 years old I have at home. 

00:30:05GONZALO BACIGALUPE And do you have a sense of how many times, how many nights that you would like her to spend with you in your home? 

00:30:10PATTI Once a week is good if she come and stay the day or night, once a week with me is fine, but when she come like one hour, half hour, she is for example, going to go see so and so to keep a board work, she will stop at my house to have a drink the water or say, hi mother, how are you? 

00:30:30SHARLEEN Two, three hours? 

00:30:30PATTI That's not a visit for me, I wanted to come with me and spend the time with me and stay with me that day. 

00:30:35SHARLEEN When I go over there, she is either on the phone or she is watching TV, I'm very, very uncomfortable in her house like to where I cannot stand sitting down because she has two dogs around and I don't like those things. I don't like the hair on my body. When I touch an animal, I wash my hands before I eat. She has two dogs, there is dog here on the couch, dog here on the floor, dog here on the chairs, there is dogs all around. I don't want to eat anything because the dishes smell like dogs, I'm not comfortable. I don't enjoy that, it's not pleasant to me. I could only do it so much at a time. I express that to her, you have dogs, I can't eat either your dishes. That's my culture, that's how I was brought up and I thought that's how she was brought up. So, she surprises me when she does these things, she makes the family unhappy because nobody wants to see dogs, it smells like dogs in her house. 

00:31:25PATTI How come you don't do the other things, you grow up and have a cold chill like, that's just the only thing you know. 

00:31:35SHARLEEN I don't — I cannot stand it, I cannot stand it. 

00:31:35PATTI And they give me so much happiness, they make me so happy, I love them so much. 

00:31:40SHARLEEN I don't like it. 

00:31:40PAT

NRNP/PRAC 6645 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:

(include psychiatric ROS rule out)

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:

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:

Differential Diagnoses:

Reflections:

Case Formulation and Treatment Plan:  

References

© 2021 Walden University Page 1 of 3

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NRNP/PRAC 6645 Comprehensive Psychiatric

Evaluation Note Template

INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY

If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignments. After reviewing full details of the rubric, you can use it as a guide.

In the Subjective section, provide:

· Chief complaint

· History of present illness (HPI)

· Past psychiatric history

· Medication trials and current medications

· Psychotherapy or previous psychiatric diagnosis

· Pertinent substance use, family psychiatric/substance use, social, and medical history

· Allergies

· ROS

· Read rating descriptions to see the grading standards!

In the Objective section, provide:

· Physical exam documentation of systems pertinent to the chief complaint, HPI, and history

· Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.

· Read rating descriptions to see the grading standards!

In the Assessment section, provide:

· Results of the mental status examination, presented in paragraph form.

· At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case .

· Read rating descriptions to see the grading standards!

Reflect on this case. Include what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations ( demonstrate critical thinking beyond confidentiality and consent for treatment !), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

(The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)

EXEMPLAR BEGINS HERE

CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why they are presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication, and referral reason. For example:

N.M. is a 34-year-old Asian male who presents for psychotherapeutic evaluation for anxiety. He is currently prescribed sertraline by (?) which he finds ineffective. His PCP referred him for evaluation and treatment.

Or

P.H. is a 16-year-old Hispanic female who presents for psychotherapeutic evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her mental health provider for evaluation and treatment.

Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.

Paint a picture of what is wrong with the patient. This section contains the symptoms that is bringing the patient into your office. The symptoms onset, the duration, the frequency, the severity, and the impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders. You will complete a psychiatric ROS to rule out other psychiatric illnesses.

Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP.

General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13.

Caregivers are listed if applicable.

Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors?

Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it)

Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. (Or, you could document both.)

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.

Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information (be sure to include a reader’s key to your genogram) or write up in narrative form.

Psychosocial History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology. However, at a minimum, please include:

· Where patient was born, who raised the patient

· Number of brothers/sisters (what order is the patient within siblings)

· Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children?

· Educational Level

· Hobbies

· Work History: currently working/profession, disabled, unemployed, retired?

· Legal history: past hx, any current issues?

· Trauma history: Any childhood or adult history of trauma?

· Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)

Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries.

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

A ssessment

Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudo hallucinations, illusions, etc.), cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.

He is an 8 yo African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking.   He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good. 

Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s treatment of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

Case Formulation and Treatment Plan.   

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions with psychotherapy, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. *see an example below—you will modify to your practice so there may be information excluded/included—what does your preceptor document?

Example:

Initiation of (what form/type) of individual, group, or family psychotherapy and frequency.

Documentation of any resources you provide for patient education or coping/relaxation skills, homework for next appointment.

Client has emergency numbers: Emergency Services 911, the Client's Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)

Reviewed hospital records/therapist records for collaborative information; Reviewed PCP report (only if actually available)

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (This relates to informed consent; you will need to assess their understanding and agreement.)

Follow up with PCP as needed and/or for:

Write out what psychotherapy testing or screening ordered/conducted, rationale for ordering

Any other community or provider referrals

Return to clinic:

Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care OR if one-time evaluation, say so and any other follow up plans.

References (move to begin on next page)

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

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