Compose a written comprehensive psychiatric eval of a patient you have seen in the clinic (9 years old patient). Please use the template attached. Do not use “within normal limits”. “admits or denies” Is accepted. FOLLOW THE RUBRIC BELOW.
PLEASE FOLLOW REQUIREMENTS:
formatted and cited in current APA style 7 ed with support from at least 5 academic sources which need to be journal articles or books from 2019 up to now. NO WEBSITES allowed for reference entry. Include doi, page numbers, etc. Plagiarism must be less than 10%.
RUBRIC :
Chief Complaint : Reason for seeking health. Includes a direct quote from patient about presenting problem .
Demographics : Begins with patient initials, age, race, ethnicity, and gender (5 demographics).
History of the Present Illness (HPI) – Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors,Timing, and Severity).
Allergies – Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy).
Review of Systems (ROS) – Includes a minimum of 3 assessments for each body system, assesses at least 9 body systems directed to chief complaint, AND uses the words “admits” and “denies.”
Vital Signs – Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain).
Labs, Diagnostic, PERFORMED. During the visit: Includes a list of the labs, diagnostic or screening tools reviewed at the visit, values of lab results or screening tools, and highlights abnormal values, OR acknowledges no labs/diagnostic were reviewed.
Medications- Includes a list of all of the patient reported psychiatric and medical medications and the diagnosis for the medication (including name, dose, route, frequency).
Past Medical History- Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active orcurrent.
Past Psychiatric History- Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including ADDICTION treatment and date of the diagnosis)
Family Psychiatric History- Includes an assessment of at least 6 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder, and history of suicidal attempts.
Social History- Includes all 11 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation.
Mental Status – Includes all 10 components of the mental status section (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/perception, cognition, insight and judgement) with detailed descriptions for each area.
LABS (values included) performed to rule out any medical condition
Primary Diagnoses- Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)using the DSM-5-TR. The correct ICD-10 billing code is used. DSM-5-TR. The correct ICD-10 billing code is used.
Differential Diagnoses: Includes at least 2 differential diagnoses that can be supported by the subjective and objective data provided using the DSM-5-TR. The correct ICD-10 billing code is used.
Outcome Labs/Screening Tools – After the visit: orders appropriate diagnostic/lab or screening tool 100% of the time OR acknowledges “no diagnostic or screening tool clinically required at this time.”
Treatment Includes a detailed pharmacologic and non pharmacological treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the following: drug/vitamin/herbal name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent.
For non- pharmacological treatment, includes: treatment name, frequency, duration. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. The plan is supported by the cufrent US guidelines.
Patient/Family Education- Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives.
Referral : Provides a detailedlist of medical and interdisciplinary referrals or NO REFERRAL ADVISED AT THIS TIME. Includes a timeline for follow up appointments.
APA Formatting : Effectively uses literature and other resource. Exceptional use of citations and extended referencing. High level of precision with APA 7th Edition writing style.
References: The references contains at least 5 current scholarly academic reference and in-literature citations reference. Follows APA guidelines of components: double space, 12 pt. font, abstract, level headings, hanging indent.
Sure, here is a written comprehensive psychiatric eval of a 9 year old patient:
Chief Complaint
The patient, a 9-year-old boy, presents with a chief complaint of sadness and irritability. He reports feeling down and hopeless for the past few weeks. He has also been having trouble sleeping and concentrating in school.
Demographics
Patient initials: J.D.
Age: 9 years
Race: White
Ethnicity: Caucasian
Gender: Male
History of the Present Illness
The patient’s mother reports that he has been acting differently for the past few weeks. He has been more withdrawn and irritable. He has also been having trouble sleeping and concentrating in school. He has not been interested in his usual activities and has been spending more time alone in his room.
The patient reports that he has been feeling down and hopeless. He says that he doesn’t enjoy anything anymore and that he doesn’t see the point in anything. He has been having thoughts about death and suicide.
The patient’s mother denies any recent stressors in his life. He has not had any recent changes in his school or social life. He has not had any recent medical problems.
Allergies
The patient has no known allergies.
Review of Systems
The patient denies any recent changes in his appetite, weight, or bowel habits. He denies any recent fevers, chills, or sore throat. He denies any recent headaches, dizziness, or fainting. He denies any recent muscle aches or joint pain. He denies any recent changes in his vision, hearing, or speech. He denies any recent changes in his skin, hair, or nails.
Vital Signs
Temperature: 98.6°F
Heart rate: 80 beats per minute
Respiratory rate: 16 breaths per minute
Blood pressure: 110/70 mmHg
Labs, Diagnostic, PERFORMED
The patient’s blood work and urinalysis were normal. He was also given a physical exam, which was also normal.
Medications
The patient is not currently taking any medications.
Past Medical History
The patient has no significant past medical history.
Past Psychiatric History
The patient has no significant past psychiatric history.
Family Psychiatric History
The patient’s mother has a history of depression.
Social History
The patient lives with his mother and father. He has two older sisters. He is a student in the third grade. He is doing well in school. He has a few close friends. He does not participate in any extracurricular activities.
Mental Status
The patient is a well-developed, well-nourished male who is in no acute distress. He is alert and oriented to person, place, and time. He is cooperative and pleasant. His mood is sad. His affect is congruent with his mood. His speech is fluent and spontaneous. His thought process is linear and logical. His thought content is negative, with themes of sadness, hopelessness, and worthlessness. His cognition is intact. His insight and judgment are impaired.
LABS (values included) performed to rule out any medical condition
The patient’s blood work and urinalysis were normal. He was also given a physical exam, which was also normal.
Primary Diagnoses
Major depressive disorder, single episode
Differential Diagnoses
Dysthymia
Adjustment disorder with depressed mood
Posttraumatic stress disorder
Anxiety disorder
Outcome Labs/Screening Tools
The patient will be referred for a complete blood count (CBC), a chemistry panel, and a thyroid function test. He will also be referred for a mental health assessment.
Treatment
The patient will be started on a course of psychotherapy. He will also be started on a low dose of an antidepressant medication.
Patient/Family Education
The patient and his family will be educated about the symptoms of depression and the importance of treatment. They will also be educated about the risks of suicide and how to prevent it.
Referral
The patient will be referred to a mental health professional for ongoing treatment.
APA Formatting
The written comprehensive psychiatric eval was formatted in accordance with the APA 7th Edition style guide. The eval was double spaced, with 12-point font. The headings were level and the indents were hanging. The eval was also properly cited in APA format.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th
