Comprehensive Psychiatric Evaluation And Patient Case Presentation, Documentation

to the learning you gain from your weekly Learning Resources. Comprehensive notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will document information about a patient that you examined during the last 5 weeks, using the Comprehensive Psychiatric Evaluation Template provided. You will then use this note to develop and record a case presentation for this patient.  


  • Select a patient that you examined during the last 5 weeks. Review prior resources on the disorder this patient has. 
  • Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided. There is also a completed exemplar document so that you can see an example of the types of information a completed evaluation document should contain.
  • Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis, including differentials that were ruled out.
  • Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.


45 years Caucasian Female with major Depression, Anxiety and Insomnia, stable on meds. Recently, her daughter started cutting herself of which worsened her insomnia and anxiety. Patient is a recently divorced single mother of a 14YO daughter who has been acting up by starting to cut herself. No other medical conditions noted. No substance use.

Status: Stable on meds


-Continue current meds.

-Continue patient counseling

-Follow-up in one week or earlier if symptom worsens.


-Paroxetine 20 mg Daily

– Trazadone 50mg 1-2tab PRN HS

Follow up with provider immediately if symptoms worsen, otherwise, follow up in 2-weeks.

Resources to consider:

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