Comprehensive Psychotherapy Evaluation

1. Compose a written comprehensive psychiatric eval of an adult patient you have seen in the clinic . 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).

BUY A PLAGIARISM-FREE ESSAY HERE

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.