Compose a written comprehensive psychiatric eval of a child patient(younger than 10 years old) you have seen in the clinic. It is not acceptable to sayt “within normal limits.”
For the Comprehensive Psychiatric Eval You will need to get it signed by your preceptor for the presentation (actual signature, not electronically typed).Work Formatted and cited in current APA style 7 ed with support from at least 5 academic sources which need to be journal articles or books from 2019 up to now. NO WEBSITES allowed for reference entry. Include doi, page numbers, etc. Plagiarism must be less than 10%.
Chief Complaint : Reason for seeking health. Includes a direct quote from patient about presenting
problem .
Demographics : Begins with patient initials, age, race, ethnicity, and gender (5 demographics).
History of the
Present Illness
(HPI) – Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors,Timing, and Severity).
Allergies – Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy).
Review of
Systems (ROS) – Includes a minimum of 3 assessments for each body system, assesses at least 9 body systems directed to chief complaint, AND uses the words “admits” and “denies.”
Vital Signs – Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain).
Labs, Diagnostic, PERFORMED. During the visit:
Includes a list of the labs, diagnostic or screening tools reviewed at the visit, values of lab results or screening tools, and highlights abnormal values, OR acknowledges no labs/diagnostic were reviewed.
Medications- Includes a list of all of the patient reported psychiatric and medical medications and the diagnosis for the medication (including name, dose, route, frequency).
