focused note

 

Subjective: What details did the patient provide regarding  their chief complaint and symptomology to derive your differential  diagnosis? What is the duration and severity of their symptoms? How are  their symptoms impacting their functioning in life? 
Objective: What observations did you make during the psychiatric assessment?  
Assessment: Discuss the patient’s mental status examination  results. What were your differential diagnoses? Provide a minimum of  three possible diagnoses with supporting evidence, and list them in  order from highest priority to lowest priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria  rules out the differential diagnosis to find an accurate diagnosis.  Explain the critical-thinking process that led you to the primary  diagnosis you selected. Include pertinent positives and pertinent  negatives for the specific patient case. 
Plan: What is your plan for psychotherapy? What is your plan  for treatment and management, including alternative therapies? Include  pharmacologic and nonpharmacologic treatments, alternative therapies,  and follow-up parameters, as well as a rationale for this treatment and  management plan. Also incorporate one health promotion activity and one  patient education strategy.
Reflection notes: What would you do differently with this  patient if you could conduct the session again? Discuss what your next  intervention would be if you were able to follow up with this  patient. Also include in your reflection a discussion related to  legal/ethical considerations (demonstrate critical thinking beyond  confidentiality and consent for treatment!), health promotion, and  disease prevention, taking into consideration patient factors (such as  age, ethnic group, etc.), PMH, and other risk factors (e.g.,  socioeconomic, cultural background, etc.).
Provide at least three evidence-based, peer-reviewed journal  articles or evidenced-based guidelines that relate to this case to  support your diagnostics and differential diagnoses. Be sure they are  current (no more than 5 years old).

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