ENTIRE CLASS:
NR548 – Psychiatric Assessment for Psychiatric-Mental Health Nurse Practitioner
NR548 Week 6: Psychiatric Interview Documentation Assignment
Preparing the Assignment
Follow these guidelines when completing each component of the assignment. Contact your course faculty if you have questions.
General Instructions
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- Download the Psychiatric Interview Template.Links to an external site.
- Watch the Psychiatric Interview RecordingLinks to an external site. and complete the required psychiatric interview documentation. Client age and allergies have been completed.
Include the following elements:
- History of present illness (HPI)
- Include the chief complaint in quotation marks
- List only HPI data
- Use appropriate terminology
- Provide support from an appropriate scholarly source or textbook to support content and terminology
- Provide information that is understandable, well-organized, and easy to follow
- Medications
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- Provide all current medication information
- Include all criteria from the medication table
- Use appropriate medical terminology
- Provide information that is understandable, well-organized, and easy to follow
- Past psychiatric history
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- Include entire past psychiatric history
- Address all criteria listed on the template
- Use appropriate terminology
- Provide support from an appropriate scholarly source or textbook to support content and terminology
- Provide information that is understandable, well-organized, and easy to follow
- Medical history
- Include all relevant medical information
- Address all criteria listed on the template
- Use appropriate terminology
- Provide support from an appropriate scholarly source or textbook to support content and terminology
- Provide information that is understandable, well-organized, and easy to follow
- Family History
- Include all pertinent family history
- Address all criteria listed on the template
- Use appropriate terminology
- Provide support from an appropriate scholarly source or textbook to support content and terminology
- Provide information that is understandable, well-organized, and easy to follow
- Social History
- Include all relevant information from the social history
- Address all criteria listed on the template
- Use appropriate terminology
- Provide support from an appropriate scholarly source or textbook to support content and terminology
- Provide information that is understandable, well-organized, and easy to follow
- Review of systems (ROS)
- Address all ROS criteria listed on the template
- Use appropriate terminology
- Provide support from an appropriate scholarly source or textbook to support content and terminology
- Provide information that is understandable, well-organized, and easy to follow
- Mental status examination (MSE)
- Include each element of the MSE
- Address all criteria listed on the template
- Use appropriate terminology
- Provide support from an appropriate scholarly source or textbook to support content and terminology
- Provide information that is understandable, well-organized, and easy to follow
- List items not addressed during the interview and discuss whether listed items were appropriately omitted or should be included. Cite a reference to support the listed items.
- Formatting
- Carlat’s (2017) textbook is used to support terminology and section content
- Sources represent a logical link between the source content and the interview documentation
- In-text citations match listed references
- Direct quotes are not used
SOLUTION
| S: Subjective
(Information the client or representative told you) |
Psychiatric Interview Template
| Initials: S. | Age: 52 | Gender: Male | ||||
| Include vital signs if provided . Document not provided if not available. | ||||||
| Height | Weight | Allergies (and reaction) | ||||
| 5’9” | 150 lbs | Medication: none
Food: shellfish-anaphylaxis Environment: none |
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| History of Present Illness (HPI) | ||||||
| Chief Complaint (CC)
|
CC is a BRIEF statement identifying why the client is here – in the patient’s own words – for instance “I have been feeling depressed,” NOT “symptoms of depression for 3 weeks.” History of Present Illness (HPI)
(1) Develops illness narrative (cogent story with clear chronology, not a list of symptoms), and (2) includes specific details of symptoms, and the impact of these symptoms on daily life. |
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| HPI
About 2 months after the client got a job promotion, the client complained of concentration problems, fatigue, and high stress and frustration levels. To capture this, he reports disruptions of sleep and that he cannot sleep at night or wakes up too early in the morning. In the last couple of weeks, he has also developed poor appetite. Although the client negates any ideas of committing suicide, he uses words such as overwhelmed and feeling “stuck .” The patient described an Axis I diagnosis of bipolar disorder and reported depressive symptomatology that seems to be influencing him at present. He’s had long-term prescriptions for mood stabilizers and for depression starting more than 5 years ago. The present stresses such as those, derived from the recent promotion, indicate a likelihood of deterioration of the subject’s depressive state due to pressure on the job.
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