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Select a group patient for whom you conducted psychotherapy for a mood disorder during the last 4 weeks. Create a Comprehensive Psychiatric Evaluation Note

Select a group patient for whom you conducted psychotherapy for a mood disorder during the last 4 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide

  • Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What was the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
  • Objective: What observations did you make during the psychiatric assessment?
  • Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.
  • Plan: What was your plan for psychotherapy (including one health promotion activity and one patient education strategy)? What was your plan for treatment and management, including alternative therapies? Include nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
  • Reflection notes: What would you do differently with this patient if you could conduct the session again?
  • Include at least five scholarly resources to support your assessment and diagnostic reasoning.

LEARNING RESOURCES:

American Group Psychotherapy Association. (2007–2020). Practice guidelines for group psychotherapy. https://www.agpa.org/home/practice-resources/practice-guidelines-for-group-psychotherapy

American Psychiatric Association. (2020). Clinical practice guidelines. https://psychiatryonline.org/guidelines

Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.

  • Chapter 23, “Assessing Mood Disorders I: Depressive Disorders”
  • Chapter 24, “Assessing Mood Disorders II: Bipolar Disorders”

Meditrek

https://edu.meditrek.com/Default.html

Note: Use this website to log into Meditrek to report your clinical hours and patient encounters.

National Institute for Health and Care Excellence

https://www.nice.org.uk/

U.S. Department of Veterans Affairs. (2020). VA/DoD clinical practice guidelines. https://www.healthquality.va.gov/

Center for Reality Therapy. (2010). Counseling with a group of not so eager clients [Video]. https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/counseling-with-a-group-of-not-so-eager-clients

College of Nurses of Ontario CNO. (2018). Therapeutic nurse-client relationship: Maintaining boundaries [Video]. YouTube. https://www.youtube.com/watch?v=mCgmyyiZ9ek

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