When issues arise within a family unit, the family often presents with one member identified as the “problem.” However, you will frequently find that the issue is not necessarily the “problem client,”

Week (enter week #): (Enter assignment title)

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6645: Psychopathology and Diagnostic Reasoning

Faculty Name

Assignment Due Date

NRNP/PRAC 6645 Comprehensive Psychiatric

Evaluation Note Template

CC (chief complaint):

HPI:

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:

ROS:

• GENERAL:

• HEENT:

• SKIN:

• CARDIOVASCULAR:

• RESPIRATORY:

• GASTROINTESTINAL:

• GENITOURINARY:

• NEUROLOGICAL:

• MUSCULOSKELETAL:

• HEMATOLOGIC:

• LYMPHATICS:

• ENDOCRINOLOGIC:

Physical exam: if applicable

Diagnostic results:

Assessment

Mental Status Examination:

Differential Diagnoses:

Case Formulation and Treatment Plan:

Reflections:

References

© 2021 Walden University Page 3 of 3