To Prepare:
(1) Reflect on the insights provided on family assessment and review the resources on psychotherapy genograms.
(2) See the Attached Comprehensive Psychiatric Evaluation Note Template and review the requirements of the documentation. There is also an exemplar provided with detailed guidance and examples.
(3) Included is also the interview Transcript for the Mother and Daughter: Cultural Tale transcript and consider how you might assess the family in the case study.
ASSIGNMENT INSTRUCTION:
(A) DOCUMENT the following for the family in the Transcript, using the Comprehensive PSYCHIATRIC EVALUATION NOTE TEMPLATE PROVIDED.
(1) Chief Complaint
(2) History of present illness
(3) Past psychiatric history
(4) Substance use history
(5)Family psychiatric/ substance abuse
(6) Psychosocial history/Developmental history
(7) Medical History
(8) Review of systems (ROS)
(9 Physical assessment ( if applicable)
(10) Mental status exam
(11) Differential diagnosis- Include a minimum of three differential diagnoses and include how you derive each diagnosis in accordance with DSM-5-TR diagnostic criteria.
(12) Case formulation and treatment plan
(13) include a psychotherapy genogram for the family
NOTE: For any item, you are unable to address from the transcript, explain how you would gather this information and why it is important for diagnosis and treatment.
