NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation

Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided in the Learning Resources. There is also a completed exemplar document in the Learning Resources so that you can see an example of the types of information a completed evaluation document should contain.

Please do not use differential diagnosis such as:

Schizoaffective disorder

Bipolar II disorder

Delusional disorder.

Please use differential diagnosis of Manic and psychotic disorders

Include introduction, purpose statement, and conclusion

Please answer all sections; These Assessment: Mental Status Examination; Differential Diagnoses; Reflections are the most important section NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation


Include intro, purpose statement, and conclusion.

 NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

CC (chief complaint):


Past Psychiatric History:

  • General Statement:
  • Caregivers (if applicable):
  • Hospitalizations:
  • Medication trials:
  • Psychotherapy or Previous Psychiatric Diagnosis:

Substance Current Use and History:

Family Psychiatric/Substance Use History:

Psychosocial History:

Medical History:

  • Current Medications:
  • Allergies:
  • Reproductive Hx:


  • HEENT:
  • SKIN:

Physical exam:

Diagnostic results:



Mental Status Examination:

Differential Diagnoses:



NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar

(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.) NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation

CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why 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 presents for psychiatric evaluation for anxiety. He is currently prescribed sertraline which he finds ineffective. His PCP referred him for evaluation and treatment.


P.H., a 16-year-old Hispanic female, presents for psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her therapist for medication 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, duration, frequency, severity, and 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.

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. Thirdly, 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. NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation

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.

Social 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


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

ROS: Cover all body systems that may help you include or rule out a differential diagnosis.  Please note: THIS IS DIFFERENT from a physical examination!

You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Physical exam From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e., General: Head: EENT: etc.

Diagnostic results: Include any labs, X-rays, Vitals or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).


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, pseudohallucinations, 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-year-old 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!), 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.).


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.

A Comprehensive Psychiatric Evaluation of a 32 Year-Old Female African American Patient with a Psychotic Disorder 

Psychotic disorders are a group of psychiatric conditions that are placed in the DSM-5 diagnostic category referred to as ‘Schizophrenia Spectrum and Other Psychotic Disorders.’ The DSM-5 is the fifth and latest edition of the Diagnostic and Statistical Manual of Mental Disorders. It is the most authoritative text used for diagnosing mental health conditions (APA, 2013). Schizophrenia Spectrum and Other Psychotic Disorders as a diagnostic category in the DSM-5 includes disorders such as schizophrenia and schizotypal disorder. As psychotic disorders, these conditions are characterised by symptomatic manifestations of abnormalities in five major areas namely disorganization of thought and speech, hallucinations, delusions, abnormalities in motor behavior such as catatonia, as well as negative symptoms including anhedonia, poverty of speech, lack of motivation, and apathy. It is known that these negative symptoms are so named because they are subtractive from the patient and potentiate an unfavorable prognosis (Sadock et al., 2015; APA, 2013). Delusions as a characteristic of psychotic disorders are fixed beliefs that the patient cannot change even when confronted with rational evidence to the contrary. They could be grandiose (the belief that one has exceptional abilities or powers), referential (the belief that gestures, comments, and so on are directed at one), persecutory (the belief that people are planning to harm one), nihilistic (the false belief in an impending disaster), erotomanic (the false belief that another person s in love with one) and so on. NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation  On the other hand, hallucinations are unreal perceptions that occur without the presence of an external stimulus. Both delusions and hallucinations must always invariably be present in a diagnosis of a psychotic disorder or condition (Sadock et al., 2015; APA, 2013). The purpose of this paper is to provide a comprehensive psychiatric evaluation of a 32 year-old female African American patient who has presented to the clinic with the diagnosis of a psychotic disorder. The evaluation gathers information that is both subjective and objective in nature to facilitate proper diagnosis and differential diagnosis.


   CC (chief complaint): The patient presented with a complaint of a persistent belief that there are family members that are plotting to harm him. He has also been hearing voices of people sent to harm him by these family members. He has lately been isolating himself and refusing to do anything including going to work. His level of functioning in interpersonal relations, work, and self-care has markedly diminished since the start of these symptoms about a month and a half ago. The symptoms have however been lingering on at a functional level for the last seven months or so.

HPI: Patient NM is a 32 year-old African American female who presents with delusions, hallucinations, and avolition that have lowered his level of functioning in interpersonal relations, occupation, and self-care. He denies any previous history of these symptoms but reports that they started appearing about one and a half months ago. The thoughts are in his mind and he cannot get them away. His belief that members of his family are plotting to harm him are constant and the voices he hears are intermittent, coming on and off. The characteristics of the symptoms are that they are persistent and very realistic in nature. They are aggravated by close proximity to family members and relieved by isolation and withdrawal from social engagements. The symptoms are noticeable both during the day and at night. The husband who is a co-historian and who brought her to the clinic rates the severity of her symptoms at 7/10.

Past Psychiatric History:

  • General Statement: Patient NM does not have a psychiatric history. She has never displayed any psychotic symptoms before and this is the first time that she is experiencing the symptoms that she has. She has also never been treated empirically with any pharmacotherapeutic or psychotherapeutic interventions for any suspected psychiatric condition.
  • Caregivers (if applicable): She has recently started neglecting her hygiene and her husband is still able to be her caregiver because at times she agrees to clean herself and eat on her own.
  • Hospitalizations: She has been hospitalized thrice before – once for a total abdominal hysterectomy due to cervical intraepithelial neoplasia (CIN) stage II or carcinoma-in-situ, once for community-acquired pneumonia, and once for pelvic inflammatory disease (PID). She has never been admitted with a psychiatric diagnosis before. She does not have a history of self-harm or suicidal/ homicidal tendencies.
  • Medication trials: Because she has not been diagnosed with a psychiatric condition before, she has never been put on any psychotropic medication.
  • Psychotherapy or Previous Psychiatric Diagnosis: Patient NM has never been diagnosed with a psychiatric condition. Because of this, she has never undergone any psychotherapeutic treatment in her life.

Substance Current Use and History: The patient is reported to have smoked at least a pack of cigarettes in two days since she was 25 years old. That is also the time she started experimenting with cannabis, which she has been using on and off when she is with a group of friends she calls “the girls.” She also takes etoh regularly after work and over the weekends. Occasionally, she engages in binge drinking with her friends over the weekends. She denies ever using opioids like cocaine. She has never used any injected substance or suffered from any withdrawal symptoms such as tremors and/ or seizures.

Family Psychiatric/Substance Use History: Patient NM is an only child to parents who are still both alive. The mother has a history of depression and attempted suicide. She is currently in remission ob sertraline (Zoloft) 100 mg orally daily. She has a history of taking etoh to suppress her depression, but she stopped. The father is a heavy smoker of at least a pack of cigarettes a day but does not drink. None of the parents has ever tried illegal substances including marijuana. The grandparents have no significant history of psychiatric illness or substance use.

Psychosocial History: Patient NM was born in Detroit, Michigan and grew up there. She also went to school there and has college education. She is an only child and does not have siblings. She is currently married but does not have any children of her own. She underwent hysterectomy three years ago and so will never have any children of her own. She lives with her husband of six years and her hobbies include socializing, travelling, reading biographies, and swimming. She has been working as a registered dietician in a nursing home until the current symptoms made her stop going to work for the last two weeks. She has a few bookings for DUI and has also been charged with the possession of marijuana without a legal prescription. There is no significant history of psychological trauma or abuse as a child for patient NM. Her parents were loving and caring, given that she was the only child. There is also no history of violence in her past, sexual or otherwise.

Medical History:

  1. Community-acquired pneumonia (admission in 2008)
  2. PID (admission in 2010)
  3. TAH (admission for surgery in 2017)
  • Current Medications:
  1. Aripiprazole (Abilify) 25 mg orally daily (used for the last 2 weeks and prescribed by her PCP for her symptoms before referral)
  2. Clozapine (Clozaril) 50 mg orally at bedtime (used in the last two weeks and prescribed by her PCP for her current symptoms before referral) (Stahl, 2017).
  • Allergies: Patient NM denies any known allergies to drugs, food or food products, and environmental allergens such as dust, smoke, and pollen.
  • Reproductive Hx: Patient NM is heterosexual. She is married but does not have children. She underwent a total abdominal hysterectomy in 2017 after a Pap smear revealed that she had carcinoma-in-situ.


  • GENERAL: Negative for weight loss, chills, fatigue, fever, or malaise.
  • HEENT: Negative for headaches. Eyes: Denies diplopia, photophobia, blurred vision, yellow sclerae, or visual loss. Ears: Denies otorrhea, tinnitus, and hearing loss. Nose: Denies epistaxis, rhinorrhea, and sneezing. Throat: Negative for dysphagia and sore throat.
  • SKIN: Negative for itching or a rash.
  • CARDIOVASCULAR: Denies palpitations, chest pains, chest tightness, or discomfort. Also denies ever having pedal edema.
  • RESPIRATORY: Negative for dyspnea, wheezing, coughing, or production of sputum. NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation
  • GASTROINTESTINAL: She denies having nausea, vomiting, diarrhea, anorexia, hematemesis, hematochezia, or melena. She also denies having abdominal pains. Reports regular bowel movements with the latest on the day of the visit to the clinic.
  • GENITOURINARY: Negative for frequency of micturition, bad odor, discoloration, hesitancy, urgency, or polyuria. Underwent TAH (no menses).
  • NEUROLOGICAL: Denies paraesthesia, syncope, dizziness, hemiparesis, ataxia, or numbness. Also denies loss of bladder or bowel control.
  • MUSCULOSKELETAL: Negative for arthralgia or myalgia. No back pain or joint stiffness.
  • HEMATOLOGIC: Negative for bleeding or bruising. Denies history of blood or clotting disorders.
  • LYMPHATICS: Denies lymphadenopathy. Also denies a history of splenectomy.
  • ENDOCRINOLOGIC: Denies polydipsia and polyuria. NO history of excessive diaphoresis, heat or cold intolerance.

Physical exam:

Vital signs: BP 125/80 regular cuff and sitting; P 75, regular; T 98.80°F; RR 18, non-labored; BMI 22.8 kg/m2 (normal BMI).

General: A&O x 3. She is dressed inappropriately for the time of the day and year and looks clearly scruffy. Her speech is disorganized, tangential, and not goal-oriented. She avoids eye contact during the interview.

HEENT: The head is atraumatic and normocephalic. Both pupils equal, round, and reacting to both light and accommodation. Extra-ocular movements are intact. External ear lobes are intact with both tympanic membranes non-perforated. No fluid level seen on otoscopy bilaterally. Nasal turbinates not inflamed and the septum is symmetrically medially placed. No rhinorrhea or sneezing. Throat is not erythematous and has no exudate.

Neck: There is no jugular distension and cervical nodes are not palpable.

Chest/Lungs: Clear fields with no wheezing, rhonchi, rales, or crepitations.  

Heart/Peripheral Vascular: S1 and S2 heard on auscultation (RRR). No evidence of a bruit, rub, gallop, or murmurs.

Diagnostic results:

  • Lab: CRP 5 mg/L; WBC 8,500
  • Radiology: MRI of the head shows no obvious structural abnormalities


  1. Mental Status Examination

The patient is a 32 year-old AA female who is alert and oriented to person and place but not to time or event. Her speech is clear but not coherent or goal-directed. There is latency of speech and monotone. The volume is soft and content impoverished. She is not dressed appropriately for the time of day or the weather. Her eye contact is avoidant but she displays no notable mannerisms, gestures, or tics. The self-reported mood is “good” while observed affect is dysphoric and incongruent to the reported mood. The thought process is tangential with perseveration and word salad. The thought content shows hallucinations, delusions, and ideas of reference. Insight and judgment are both poor and impaired. There is however no suicidal or homicidal ideation. Diagnosis: Schizophrenia [295.90 (F20.9)].

  1. Differential Diagnoses
  2. Schizophrenia

The most likely primary diagnosis for patient NM is schizophrenia. This is because the symptomatology displayed conforms to the DSM-5 diagnostic criteria for that psychotic disorder. For a diagnosis of schizophrenia to be made: (A) there must be at least two of: delusions, catatonic behavior, hallucinations, negative symptoms like avolition, and incoherence or disorganization of speech; (B) the level of functioning in at least one area (self-care, interpersonal relations, or work) must have reduced significantly because of the symptoms in (A) above; (C) the disturbance must have persisted for a total period of six months; (D) other psychotic disorders such as schizoaffective disorder and bipolar disorder with psychotic features must have been excluded; (E) the symptoms must not be attributable to a medication or substance use; and (F) the patient has no childhood history of autism spectrum disorder or a communication disorder (Sadock et al., 2015; APA, 2013). This diagnosis has been made after critical thinking with regard to comparing the patient’s symptoms to the DSM-5 diagnostic criteria (Sadock et al., 2015; APA, 2013; Stahl, 2013). Patient NM meets the criteria perfectly and is therefore most likely suffering from schizophrenia as a psychotic disorder. NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation

  1. Substance-Induced psychotic Disorder

This is the second possible differential diagnosis for patient NM, especially given that she has a significant history of substance abuse. The DSM-5 states that patients with this kind of disorder have symptoms that are very similar to schizophrenia and fulfill criterion (A) above as explained. The differentiating characteristic is that the symptoms will be present when the substance is being used but disappear when the use of the substance is stopped for whatever reason (APA, 2013). In other words, the patient characteristically undergoes remission when the substance is stopped.

  1. Schizotypal Personality Disorder

Schizotypal personality disorder is the third possible differential that could be true for patient NM. It is distinguished from schizophrenia by the presence of symptoms that do not fully fulfill the diagnostic criteria for schizophrenia. The symptoms are then characteristically referred to as being sub-threshold (APA, 2013).



The comprehensive psychiatric evaluation performed for this patient follows all the tenets required for assessing a psychiatric patient. I followed all the rules and steps of assessing such a patient as stated by revered authorities in the field of physical assessment (Ball et al., 2019; Bickley, 2017; LeBlond et al., 2014). Because of this, I would not do anything differently were I to start all over again the process of psychiatric evaluation for thus patient. The assessment or evaluation respected the principle of informed consent which was obtained every time the patient was evaluated. I avoided annoying the patient by being cognizant of autonomy as a bioethical principle (Haswell, 2019; Entwistle, 2019). I also avoided causing her psychological trauma by insinuating ho sick she was. This was in respect of the bioethical principle of nonmaleficence. For health promotion, I would advise the patient’s family to go for family therapy (Corey, 2017) so that they may be able to cope with their loved one’s psychiatric diagnosis and treatment. The husband will also be advised to try and keep her away from environments that may encourage her to use substances or smoke. This is because of her past history.


This 32 year-old female AA patient showed classical symptoms of the psychotic disorder referred to as schizophrenia. On evaluation, she displayed delusions, hallucinations, avolition (a negative symptom of schizophrenia), reduced level of functionality in social, occupational, and self-care circles. She was also exhibiting incoherent speech and tangential thought. This made the primary diagnosis of schizophrenia more probable when this symptomatology was compared to the diagnostic criteria of the condition in the DSM-5. Possible differential diagnoses for her are substance-induced psychosis and schizotypal personality disorder.


American Psychiatric Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5th ed. Author.

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9th ed. Elsevier.

Bickley, L.S. (2017). Bates’ guide to physical examination and history taking, 12th ed. Wolters Kluwer.

Corey, G. (2017). Theory and practice of counselling and psychotherapy, 10th ed. Cengage Learning.

Entwistle, J.W.C. (2019). Noninformed consent and autonomy. The Annals of Thoracic Surgery, 108(6), 1610.

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179.

LeBlond, R.F., Brown, D.D., & DeGowin, R.L. (2014). DeGowin’s diagnostic examination, 10th ed. McGraw Hill Medical.

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11th ed. Wolters Kluwer.

Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6th ed. Cambridge University Press.

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications, 4th ed. Cambridge University Press. NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation