Comprehensive Psychiatric Evaluation
Submit a Comprehensive psychiatric evaluation on a adult and aging adult with a mental illness. Give a short synopsis of the case and why the patient has come to see you.
Comprehensive Psychiatric Evaluation
Source of Information
CASE PRESENTATION (Presenting features, medical/social/family history of Mental illness.)
Demographics should include: age, sex, who they live with, who they are accompanied by for your interview, who referred them to you.
Chief Complaint of Patient: Patient’s words
History of Present Illness
Current Medications
Past Psychiatric History
Past Psychiatric Medications
Substance Use/Abuse
Medical History
Allergies
Family History
Psychiatric and Addiction History
Developmental and Social History
MSE:
Appearance and behavior
Mood
Affect
Thought content
Thought process
Perceptual disturbances
Cognition
Abstract Reasoning
Concentration
Impulsivity
Insight
Judgment
Threat to self or others
Motivation
Strength and Weakness
Motor activity
Speech
DIAGNOSTIC TESTS
CASE FORMULATION
DIFFERENTIAL DIAGNOSIS (with rationale based on DSM 5 and findings
DIAGNOSIS: (Include ICD 10 codes)
Treatment Plan:
Pharmacology
Psychotherapy
Referrals
Patient Education
FOLLOW-UP
Rubric
Exemplary
Proficient
Developing
Emerging
Absent
5
4
3
2
0
Identifying data
SUMMARY
BACKGROUND
CASE PRESENTATION
Complete and
Appropriate
Incomplete
Appropriate
Complete
Not all appropriate
Partially complete
Not all appropriate
None present
10
7
5
3
0
Chief Complaint History of Present Illness
Current Medications
Past Psychiatric History
Past Psychiatric Medications
Substance Use/Abuse
Complete and
Appropriate
Incomplete
Appropriate
Complete
Not all appropriate
Partially complete
Not all appropriate
None present
10
8
6
4
0
Medical History
Allergies
Family History – Psychiatric and Addiction History. Developmental and Social History
Complete and
Appropriate
Incomplete
Appropriate
Complete
Not all appropriate
Partially complete
Not all appropriate
None present
5
4
3
2
0
DIAGNOSTIC TESTS
Complete and
Appropriate
Incomplete
Appropriate
Complete
Not all appropriate
Partially complete
Not all appropriate
None present
10
8
6
4
0
Mental Status Exam
Strength and Weakness
Complete and
Appropriate
Incomplete
Appropriate
Complete
Not all appropriate
Partially complete
Not all appropriate
None present
15
10
8
5
0
Case Formulation
Complete and
Appropriate
Incomplete
Appropriate
Complete
Not all appropriate
Partially complete
Not all appropriate
None present
20
15
10
5
0
Differential Diagnoses with rationale
Diagnosis with
DSM coded
Complete and
Appropriate
Incomplete
Appropriate
Complete
Not all appropriate
Partially complete
Not all appropriate
None present
15
10
8
5
0
Treatment Plan:
Pharmacology
Psychotherapy
Referrals
Patient Education
Complete and
Appropriate
Incomplete
Appropriate
Complete
Not all appropriate
Partially complete
Not all appropriate
None present
10
8
6
4
0
FOLLOW-UP
DISCUSSION
Professional
Presentation
Written or Oral
Complete
And professionally presented
Incomplete but
Professionally presented
Complete
But needs assistance with grammar or set-up or dictation organization
Incomplete and not professionally presented
Not professionally done