SAMPLE from another student

The patient should be comprehensively assessed before offering the patient and care. Family therapy which is also referred to as family counseling is a form of therapy that is designed to address specific issues that affect the health and functioning of the family (McGoldrick & Hardy, 2019). Therefore, it is important to address and consider all member problems and concerns. Healthcare providers should explore presenting conditions of the patient to be able to determine if they are impacted by family interactions. This paper will be addressing comprehensive family psychiatric evaluation and family therapy. Demographic Data Patti presented to the clinic in the company of her daughter Sharleen. The family had immigrated from Iran to the United States to seek medical help for one of the daughters. Patti had left behind the third-born daughter in Iran with her husband but she later joined the family and they divorced her husband and he remarried. She has had two surgeries on her feet which failed and now she is disabled. History of Presenting Illness Patti is an Iranian immigrant who presented to the clinic in the company of one of her daughters Sharleen after she was referred for psychiatric review. She has been reporting feeling hopeless, helpless, feels that her children are out of control and she cannot be in charge and that her children do not need her anymore. Patti and her daughters have a history of being through traumatic conditions which include immigrating from Iran to the United States, a history of being 3 through battering and domestic violence back in Iran, and her third-born daughter who was left behind when they immigrated was sexually abused by her father. The family as a whole had visited a therapist for two sessions since when her daughter who was left behind joined them two years ago and told them of what she had gone through and she was blaming Patti which resulted in the family having chaos. Patti has a history of undergoing two surgeries on her feet but they failed which resulted in her becoming disabled which resulted in more tension and anxiety in the family. Patti was reported by the family therapist to be living in her traditional ways and her daughters were detaching from her to live their own life and this made her more concerned since in her tradition children are supposed to take care of their parents when sick and in old age. This resulted in arguments since her children report that she should learn to live independently since they also are trying to create their own life. Patti also complains that her children do not spend enough time with her but Sharleen her daughter reports that she tries to visit her almost six days a week but Patti is always on her phone or watching television. Patti reports that she spends a very small amount of time with her which she does not appreciate. Past Psychiatric History Her past psychiatric history has not been documented. Medical History Her past medical history has not been discussed although it should be documented. Substance use History This history and information have not been documented. Family Psychiatric History 4 Patti and her family attended two therapy sessions after which the others stopped but she and Sharleen have been attending therapies for the last one and a half years. Psychosocial History Patti is a single mother of 5 who was born and raised in Iran, she immigrated to the United States to seek medical help for one of her children but she settled here. Her education level was not documented but she is a Muslim but does not attend the mosque due to her disability. She reports that her hobbies include watching religious teachings and playing phone games. She currently lives with her last-born son who is 15 years old but the others live away but they come to visit her regularly. History of Abuse/Trauma Her third-born daughter was sexually abused by her father after she was left behind when they immigrated, and the family has a history of facing battering and physical violence. Review of Systems GENERAL: She denies loss of appetite, fever, weakness, weight changes, chills, fatigue, or intolerance to heat or cold. HEENT: Head- Denies head trauma, dizziness, or headache. Eye: Denies eye discharge, excessive tearing, blurring of vision, double vision, or loss of vision. Ear: Denies ear discharge, loss of hearing, or earache. Nose: Denies rhinorrhea, nasal congestion, or nose bleeding. Throat: She denies painful swallowing or any difficulty in swallowing. SKIN: She denies skin changes, rashes, or itchiness. CARDIOVASCULAR: She denies shortness of breath, palpitations, edema, or chest pains. 5 RESPIRATORY: She denies cough, tachypnea, wheezing, or sputum production. GASTROINTESTINAL: She denies nausea, loss of appetite, abdominal pains, heartburn, vomiting, diarrhea, or constipation. GENITOURINARY: She denies frequency, incontinence, urgency, oliguria, polyuria, burning sensation during micturition, or vaginal discharge. NEUROLOGICAL: She has a disability in both lower limbs but denies syncope, tingling sensation, dizziness, numbness, headache, or ataxia. MUSCULOSKELETAL: She has pain in both feet but denies joint swelling and back pain. HEMATOLOGICAL: She denies anemia, easy bruising, or bleeding. LYMPHATICS: She denies lymphadenopathy or splenectomy. ENDOCRINOLOGIC: She denies recent weight changes, intolerance to cold or heat, polyphagia, polyuria, or excessive sweating. Physical Assessment (if applicable) There is no physical examination that will be necessary for this patient. Mental Status Exam Patti is a woman who is in a good nutritional status, dressed appropriately, well-kempt, with a well-built body. She is alert and oriented to time place and person. She uses a wheelchair since she is disabled on both lower limbs, her speech is comprehensive and fluent and it is in the right tone and volume. She has a normal affect and mood, and her thought process is logical and 6 she is cooperative during the assessment and maintains eye contact. Her intellect is a global impression and her memory both long term and short term is intact. Differential Diagnosis Parent-child relation problem According to Niec et al. (2016), parent-child relation problems refer to communication difficulties and challenges in interactions that occur between parents and children and it can occur at any time of child development. The parents mostly exhibit excessive protection and parenteral pressure which can progress to become arguments and sometimes physical violence. The actions of the parents result in the child avoiding them and the child can become angry, sad, or apathetic against the parent. Disruption of the family by separation and divorce Disruption of the family by separation and divorce results in the development of new roles to family members which can result in the children becoming rebellious and withdrawn (Gager et al., 2016). This results in the family experiencing increased emotional dysregulation and mental health disruption. The patient in the case study has a history of her children becoming withdrawn and there was emotional instability of the majority of family members. The Acculturation difficulty Al Wekhian (2016) highlighted that acculturation difficulty is having problems or inability to adapt to a new culture or environment setting. They can include discrimination, conflicts of cultural beliefs, and/or bias along with other issues that occur as a result of migration 7 and social transplantation. The patient in the case study and her family had immigrated from Iran to the United States and Patti is still holding on to her cultural beliefs and lifestyle. Case Formulation Patti and her daughter Sharleen have been attending therapy for the last one and a half years due to family chaos. Patti has also been feeling helpless, hopeless, and she has been feeling that her children are also out of her control which resulted in them attending family therapy. She complains that with her being disabled and unable to work, she expects her children to be able to assist her as her culture requires them to. Her children have been detaching themselves and they want to start a life on their own which Patti did not agree with. Treatment Plan For the treatment of this family, they will be encouraged to continue with family therapy and the rest of the family members will also be encouraged to attend the sessions. They will be scheduled to have a therapy session every week. The third-born daughter will also be contacted and convinced of the importance of undergoing therapy especially since she was the one who was sexually assaulted. Conclusion Conclusively, when attending to a group of individuals or a family, it is important to consider the feelings and thoughts of every member of the group. Becvar & Becvar (2017) highlighted that during family therapy, healthcare providers should utilize the information provided to be able to diagnose and plan the treatment plan of the patient. Family mental illnesses can result in frustrations and negative interactions among the family members. Family therapy focuses on the emotions and feelings of the family members to ensure that every member 8 is satisfied. For family therapy to be competent, healthcare providers should ensure they assess the family comprehensively to be able to determine the dysfunctional and functional part of the family.

Assignment: 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.

To prepare:

· Review this week’s Learning Resources and reflect on the insights they provide on family assessment. Be sure to review the resource on psychotherapy genograms.
· Download the Comprehensive Psychiatric Evaluation Note Template and review the requirements of the documentation. There is also an exemplar provided with detailed guidance and examples. 
· View the Mother and Daughter: A Cultural Tale video in the Learning Resources and consider how you might assess the family in the case study.
The Assignment
Document 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)
· 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

Here is the website for the video Mother and Daughter: A Cultural Tale. . (2003).[Video/DVD] Masterswork Productions. Retrieved from https://video.alexanderstreet.com/watch/mother-and-daughter-a-cultural-tale

Here is the story in the video

The Patient(s) have been through three types of trauma
The mother and daughter video consist of; Hx of domestic violence, child sexual abuse, and hx of immigration which related to trauma.
There’s a mother that has 5 children, they have to leave their home in Iran to America but sadly one of the children were left behind and the child that was left behind was raped by her father
The mother was a caregiver but currently experiencing a traumatic illness, she is disabled and unable to walk/working. The interview/paper will address different forms of trauma and the way the younger adult with biracial few life
the patients names who presented in the video are Patti and Sharleen, the mother being Patti and the daughter being named Sharleen they have both been going to therapy for 1 and a half years. (their therapist was present during the interview and the interviewer
as I mentioned before when they were evicted out of their home her 8 year old daughter was left behind later got a visa and was able to travel to America
Shirin is the name of the girl that was left behind she migrated from Iran to America and she is now 21 years old
Patti live in her traditional matter and how she believes she should raise her child due to religion
Patti has had surgery on both of her feet, and the surgery failed that’s why she’s partly disabled
Patti depends on the kids a lot and expect them to be with her for the rest of her life
The daughter Sharleen says that her mother expect her to be there when she’s bored to entertain her but Sharleen says that she can’t because she’s busy and has a lot to do which eventually leads to them having a huge argument
The daughter presented in the video Sharleen represented the rest of the kids ( 2 other girls and 2 boys; the boys are 15 and 18years)
Patti says she feels depressed saying she doesn’t see her children enough, Sharleen on the other hand says she visited her 6/7 days of the week and that her mom got mad at her for not coming on the 7th day when Sharleen had to get some work done
Sharleen states that she has mentioned this to her mother before and says her mother takes it personal
Sharleen’s mother and father don’t get along well. Her mother has little patient’s and takes it out on others. The daughter wants to live her life and doesn’t want her mother to rely on her and her siblings always
The mother’s likes to have visitors, the daughter states that most of the time the mother is either watching TV or using her phone
Before Patti’s foot surgery she was an independent woman and works as caregive
The daughter that was left behind with her father mentioned when she came to the US saying that her father abused her mentally, sexually and physically and she blamed her mother for the outcome
After she mentioned this hell broke out in this household, there was arguments every second and they were cursing each others out until they started therapy
They both want peace in Shira’s life and for her to experience life, Sharleen want Shira to be more calm so she can talk to her better
Sharleen hates animals due to the way she was raised “I don’t like them, that’s how I was brought up’ but her mom has two dogs which the kids dislike
ROBERTA(one of the reflective therapist) said that she was impressed at how vibrant and younger patti look and that’s he was also impressed AT HOW SHARLEEN WAS ABLE TO EXPRESS HERSELF
Dorothy (one of the reflective therapist) says she senses how sandy connects with the family she also stats that she can relate to patti that it’s a tragedy to see her six children slip away one by one
Dorothy also notices how well patti raised her children
Amber (one of the reflective therapist) was impressed byt the way they immigrated and how or what purpose did she want to pursue for her and her children to come to America
Sharleen states that her mom wants to choose her happiness and her mom is too controlling.
Patti sometimes thinks its not fair what happened in the relationship she had whit her husband and doesn’t want the same for her children’s and Sharleen thinks that Patti shouldn’t try sand control her life
Sharleen wants her mother to be more calm, independent, less frustrated and stop expecting much from them.
Patti feels hopeless, helpless and experience anxiety one in a while over the family issues and her health states

RUBRIC: 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.
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.
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.
The assignment includes an accurate, clear, and complete genogram of the client family. The documentation style is consistent and a key is provided.
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.
Uses correct grammar, spelling, and punctuation with no errors. Uses correct APA format with no error

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).

A

ssessment

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.

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