Posted: June 15th, 2022

Discuss the patient’s mental status examination results

Learning Resources

American Group Psychotherapy Association. (2007–2020). Practice guidelines for group psychotherapy. https://www.agpa.org/home/practice-resources/practice-guidelines-for-group-psychotherapy

American Psychiatric Association. (2020). Clinical practice guidelines. https://psychiatryonline.org/guidelines

Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
• Chapter 23, “Assessing Mood Disorders I: Depressive Disorders”
• Chapter 24, “Assessing Mood Disorders II: Bipolar Disorders”

National Institute for Health and Care Excellence
https://www.nice.org.uk/

U.S. Department of Veterans Affairs. (2020). VA/DoD clinical practice guidelines. https://www.healthquality.va.gov/

To Prepare
• 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 disorder during the last 4 weeks. Create a Comprehensive Psychiatric Assessment 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 Assessment notes must be signed, and each page must be initialed by your Preceptor. Include at least five scholarly resources to support your assessment and diagnostic reasoning. Choose a group patient with a mood disorder for whom you’ve done psychotherapy in the last 4 weeks. Use the template in the Learning Resources to make a Comprehensive Psychiatric Assessment Note for this patient. As an example and guide, there is also a template that has already been filled out. All psychiatric Assessment notes need to be signed, and your Preceptor needs to initial each page. Include at least five academic sources to back up your Assessment and diagnosis.

The Assignment

• 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.
o 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?
o Objective: What observations did you make during the psychiatric assessment?
o 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.
o 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?
o Reflection notes: What would you do differently in a similar patient Assessment? Reflect on one social determinant of health according to the Healthy People 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.

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