Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Comprehensive psychiatric evaluation notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will document information about a patient that you examined in a group setting during the last 4 weeks, using the Comprehensive Psychiatric Evaluation Note Template provided. You will then use this note to develop and record a case presentation for this patient.

• Review this week’s Learning Resources and consider the insights they provide about clinical practice guidelines.
• Select a group patient for whom you conducted psychotherapy for a mood disorderduring 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. All psychiatric evaluation notes must be signed by your Preceptor. When you submit your note, you should include the complete comprehensive psychiatric evaluation note as a Word document and pdf/images the completed assignment signed by your Preceptor. You must submit your note using Turnitin.
  Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Grading Policy.
• Then, based on your evaluation of this patient, develop a video presentation of the case. Plan your presentation using the Assignment rubric and rehearse what you plan to say. Be sure to review the Kalturasupport resources in the Classroom Support Center found by clicking on the Help
• Include at least five scholarly resources to support your assessment and diagnostic reasoning.
• Ensure that you have the appropriate lighting and equipment to record the presentation.

Record yourself presenting the complex case for your clinical patient.

Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video.

In your presentation:

• Dress professionally and present yourself in a professional manner.
• Display your photo ID at the start of the video when you introduce yourself.
• Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
• Present the full complex case study. Be succinct in your presentation, and do not exceed 8 minutes. Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.
  • 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-TR diagnostic criteria and is supported by the patient’s symptoms.
  • Plan: Describe your treatment modality and your plan for psychotherapy. Explain the principles of psychotherapy that underline your chosen treatment plan to support your rationale for the chosen psychotherapy framework. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this psychotherapy session?
  • Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
  • Consider the experiences you have had thus far, either in the healthcare workplace or at your practicum site. As you likely know, a nurse’s job does not begin and end with one-to-one patient contact. It includes meetings, documentation, trainings, and collaboration. In particular, the nurse is a member of an interdisciplinary team and must use oral and written communication to inform others of a patient’s status. A central skill of advanced practice nursing, then, is the ability to present a patient’s history, symptoms, diagnosis, and treatment plan to relevant parties involved in treatment.This week, in addition to your Meditrek tracking, you will develop a comprehensive psychiatric evaluation note and video case presentation on one of the patients from a group you have interacted with in your clinical practicum.
  • CASE
  • Group counseling for individuals with schizophrenia attending for the first time . We have 5 with the same diagnosis being schizophrenia .This group session aim is to create a supportive environment where participants can share their experiences, foster connections, and begin the journey toward understanding and managing their symptoms. Patients are assured they are in a safe and non-judgmental space.Participants share one common experience or feeling related to their schizophrenia.This activity helps establish common ground and encourages empathy among group members, they have the opportunity to share their experiences with schizophrenia, including challenges and successes.The group is guided through a mindfulness exercise to promote present-moment awareness and relaxation. the session remains focused on providing support, understanding, and encouragement for participants. Ongoing adjustments to the group dynamics, facilitation style, and content are made to accommodate the unique needs and comfort levels of individuals attending for the first time.