When issues arise within a family unit, the family often presents with one member identified as the “problem.” However, you will frequently find that the issue is not necessarily the “problem client,”

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When issues arise within a family unit, the family often presents with one member identified as the “problem.” However, you will frequently find that the issue is not necessarily the “problem client,” but rather dysfunctional family patterns and relationships. To better understand such patterns and relationships, and develop a family treatment plan, it is essential that the practitioner appropriately assess all family members. This requires you to have a strong foundation in family assessment and therapy. This week, you practice assessing and diagnosing client families presenting for psychotherapy.

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.

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THE ASSIGNMENT

Document the following for the family in the video (transcript of video provided), 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-TR diagnostic criteria
  • Case formulation and treatment plan

  • Include a psychotherapy genogram for the family

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.

*** PLEASE NOTE THE COMPREHENSIVE EVALUATION TEMPLATE THAT IS TO BE USED FOR THIS ASSIGNMENT IS ATTACHED

** ALSO AN EXAMPLE COMPREHENSIVE EVALUATION IS ATTCHED TO NOTE ALL ASPECTS THAT ARE TO BE COVERED AND WHAT INFORMATION IS NEEDED

** THE TRANSCRIPT OF THE VIDEO THAT IS TO BE USED FOR THIS ASSIGNMENT IS ATTACHED

**THE RUBRIC FOR GRADING IS ATTACHED

AT LEAST 3 SCHOLARY PEER-REVIEW REFERENCES NOT OLDER THAN 3 YEARS

When issues arise within a family unit, the family often presents with one member identified as the “problem.” However, you will frequently find that the issue is not necessarily the “problem client,”
Week (enter week #): (Enter assignment title) Student Name College of Nursing-PMHNP, Walden University NRNP 6645: Psychopathology and Diagnostic Reasoning Faculty Name Assignment Due Date NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Template 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: Physical exam: if applicable Diagnostic results: Assessment Mental Status Examination: Differential Diagnoses: Case Formulation and Treatment Plan: Reflections: References © 2021 Walden University Page 3 of 3
When issues arise within a family unit, the family often presents with one member identified as the “problem.” However, you will frequently find that the issue is not necessarily the “problem client,”
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). Assessment 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 assessment and diagnostic impression 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 (demonstrating critical thinking beyond confidentiality and consent for treatment!), social determinates of health, 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. © 2021 Walden University Page 7 of 7
When issues arise within a family unit, the family often presents with one member identified as the “problem.” However, you will frequently find that the issue is not necessarily the “problem client,”
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. 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 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. 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. 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. 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. 5 pts

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