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Extensive Psychiatric Evaluation


Case Presentation – Extensive Psychiatric Evaluation

Demographic Data:

Includes identifying information including initials, age, gender, and ethnicity. The primary source of information and reliability, as well as the reason for referral and patient understanding of referral, are clear.

Subjective Data History of Present Illness (HPI)

Chief complaint (CC) is clear, concise, and verbatim from pt. HPI is thorough yet concise and provides a chronological account of symptoms and contextual factors that are sufficiently descriptive (old carts) to validate Dx per DSM-5 criteria. All pertinent negatives are included. A longitudinal course of illness is clear. Current psychiatric medications and responses are included.

Past Psychiatric History

PPH contains all previous treatments including previous Dx, hospitalizations, outpatient treatments, suicide attempts, self-harm, and previous medications with a detailed trial and response history. Pertinent negatives are also included.

Substance Use History

Complete substance use history is documented. Pertinent negatives are clear evidenced by appropriate pt. responses ie. “denies”. Age of onset, duration, frequency/pattern of use, route of administration, last use, consequences of use. Not limited to illicit substances. Inclusive of addictive behavioral patterns.


Past Medical History

Medical history includes previous and current medical problems, surgeries, and allergies.


 Review of Systems (ROS)

ROS is germane to the presenting psychiatric problems and is free from objective assessment data ie. “lungs clear” “BS present”. Etc.


Family History Psychosocial and Developmental History

Family Hx includes identified relational status with current or historical psych illness, treatments, responses, suicides, or self-harm. Indication if biologically related. Dev’t Hx includes info regarding family of origin, siblings, birth order, family dynamics, relational patterns and status, educational, employment, abuse, spirituality, legal, military. Dev’t milestones for child & adolescents are included.

Objective Data: 

Mental Status Exam 

MSE contains all elements as outlined in the addendum. Is in narrative form and effectively and vividly describes the patient’s presentation. Concrete examples of all assessment results are included ie. “able to correctly interpret 2/3 simple proverbs” to validate documentation of “abstract thought intact”.


Physical Exam (as appropriate) vital signs, height, weight, labs or other relevant screening.


Assessment (Diagnosis)

Actual diagnosis (s) is pertinent to the signs and symptoms( S&S), the formulation contains evidence of critical thought and subject knowledge, and reasonable diagnoses are made per DSM-5. Clearly met criteria for diagnoses tendered are explicit in the HPI description and substantiated with the MSE. Include the neurobiology of the disease.


Differential diagnoses

At least two differential diagnoses. The differential is pertinent to S&S, the formulation contains evidence of critical thought and subject knowledge, and reasonable diagnoses are made per DSM-5. Clearly met criteria for diagnoses tendered are explicit in the HPI description and substantiated with the MSE.


Evidence-based treatment plan (chosen medication dosage and frequency) is presented with detailed rationales. Include the neurobiology of the medication action. The level of detail reflects the student’s ability to choose treatments based not only on FDA approval or current evidence but also on the nuances and unique characteristics of each. The treatment plan is holistic and comprehensive. There is strong evidence of the student’s synthesis of information and critical thought 


Writing, Support, APA

The format is consistent with the example provided in the course. Strong, recent (5-7 years), scholarly, peer-reviewed support of topics. No grammar, spelling, and punctuation errors. Writing mechanics are consistent with formal scholarly work. No errors in APA style based upon the required APA manuals 





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