Page of 6 ZOOM INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY I

Page
of 6
ZOOM
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 assignment in Weeks 4–10. After reviewing the
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-TR diagnostic criteria for each
differential diagnosis and explain what DSM-5-TR 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: Discuss what you learned and what you might do
differently. Also include in your reflection a discussion related to legal/ethical
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considerations (demonstrate 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.).
(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 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 presents for psychiatric evaluation for anxiety. He is
currently prescribed sertraline which he finds ineffective. His PCP referred him for
evaluation and treatment.
Or
P.H., a 16-year-old Hispanic female, presents for psychiatric evaluation for
concentration difficulty. She is not currently prescribed psychotropic medications. She is
referred by her therapist for medication 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. First what is bringing the patient to your
evaluation. Then, include a PSYCHIATRIC REVIEW OF SYMPTOMS. The symptoms
onset, duration, frequency, severity, and impact. Your description here will guide your
differential diagnoses. You are seeking symptoms that may align with many DSM-5-TR
diagnoses, narrowing to what aligns with diagnostic criteria for mental health and
substance use disorders.
Past Psychiatric History: This section documents the patient’s past treatments. Use
the mnemonic Go Cha MP.
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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. Thirdly, 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.
Social 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?
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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
ROS: Cover all body systems that may help you include or rule out a differential
diagnosis. Please note: THIS IS DIFFERENT from a physical examination!
You should list each system as follows: General: Head: EENT: etc. You should list
these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears,
Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No
palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain
or blood.
GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or
tingling in the extremities. No change in bowel or bladder control.
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MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or
polydipsia.
Physical exam (If applicable and if you have opportunity to perform—document if
exam is completed by PCP): From head to toe, include what you see, hear, and feel
when doing your physical exam. You only need to examine the systems that are
pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must
describe what you see. Always document in head-to-toe format i.e., General: Head:
EENT: etc.
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, pseudohallucinations, 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-year-old 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
diagnostic impression selection. You will use supporting evidence from the literature to
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support your rationale. 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.).
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.