NR548 Week 6: Psychiatric Interview Documentation Assignment

NR548 – Psychiatric Assessment for Psychiatric-Mental Health Nurse Practitioner

NR548 Week 6: Psychiatric Interview Documentation Assignment
Preparing the Assignment
Follow these guidelines when completing each component of the assignment. Contact your course faculty if you have questions.
General Instructions

Download the Psychiatric Interview Template.Links to an external site.
Watch the Psychiatric Interview RecordingLinks to an external site. and complete the required psychiatric interview documentation. Client age and allergies have been completed.

Include the following elements:

History of present illness (HPI)

Include the chief complaint in quotation marks
List only HPI data
Use appropriate terminology
Provide support from an appropriate scholarly source or textbook to support content and terminology
Provide information that is understandable, well-organized, and easy to follow

Medications

Provide all current medication information
Include all criteria from the medication table
Use appropriate medical terminology
Provide information that is understandable, well-organized, and easy to follow

Past psychiatric history

Include entire past psychiatric history
Address all criteria listed on the template
Use appropriate terminology
Provide support from an appropriate scholarly source or textbook to support content and terminology
Provide information that is understandable, well-organized, and easy to follow 

Medical history

Include all relevant medical information
Address all criteria listed on the template
Use appropriate terminology
Provide support from an appropriate scholarly source or textbook to support content and terminology
Provide information that is understandable, well-organized, and easy to follow

Family History

Include all pertinent family history
Address all criteria listed on the template
Use appropriate terminology
Provide support from an appropriate scholarly source or textbook to support content and terminology
Provide information that is understandable, well-organized, and easy to follow

Social History

Include all relevant information from the social history
Address all criteria listed on the template
Use appropriate terminology
Provide support from an appropriate scholarly source or textbook to support content and terminology
Provide information that is understandable, well-organized, and easy to follow

Review of systems (ROS)

Address all ROS criteria listed on the template
Use appropriate terminology
Provide support from an appropriate scholarly source or textbook to support content and terminology
Provide information that is understandable, well-organized, and easy to follow

Mental status examination (MSE)

Include each element of the MSE
Address all criteria listed on the template
Use appropriate terminology
Provide support from an appropriate scholarly source or textbook to support content and terminology
Provide information that is understandable, well-organized, and easy to follow
List items not addressed during the interview and discuss whether listed items were appropriately omitted or should be included. Cite a reference to support the listed items.

Formatting

Carlat’s (2017) textbook is used to support terminology and section content
Sources represent a logical link between the source content and the interview documentation
In-text citations match listed references
Direct quotes are not used

 
SOLUTION

S: Subjective
(Information the client  or  representative told you)

Psychiatric Interview Template

Initials: S.
Age: 52
Gender: Male

Include vital signs if provided . Document not provided if not available.

Height
Weight
Allergies (and reaction)

5’9”
150 lbs
Medication: none
Food: shellfish-anaphylaxis
Environment: none

History of Present Illness (HPI)

Chief Complaint (CC)
 
CC is a BRIEF statement identifying why the client is here – in the patient’s own words – for instance “I have been feeling depressed,” NOT “symptoms of depression for 3 weeks.” History of Present Illness (HPI)
(1) Develops illness narrative (cogent story with clear chronology, not a list of symptoms), and
(2) includes specific details of symptoms, and the impact of these symptoms on daily life.

HPI
About 2 months after the client got a job promotion, the client complained of concentration problems, fatigue, and high stress and frustration levels. To capture this, he reports disruptions of sleep and that he cannot sleep at night or wakes up too early in the morning. In the last couple of weeks, he has also developed poor appetite. Although the client negates any ideas of committing suicide, he uses words such as overwhelmed and feeling “stuck .”
The patient described an Axis I diagnosis of bipolar disorder and reported depressive symptomatology that seems to be influencing him at present. He’s had long-term prescriptions for mood stabilizers and for depression starting more than 5 years ago. The present stresses such as those, derived from the recent promotion, indicate a likelihood of deterioration of the subject’s depressive state due to pressure on the job.
 
 
 

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