Political polls typically sample randomly from the U.S population to investigate the percentage of voters who favor some candidate or issue. The number of people polled is usually on the order of 1000
July 10, 2019
Determine how the recommendations may impact the APRN role/setting and practice dimensions
July 10, 2019

Most Helpful Information

Assessment Form

I selected an interview assessment tool that is specific to adults and was found from the Northeast Georgia Physicians Group (2019). What I like about the format of this interview assessment is the comparison between what the client reports and what the clinician observes. The client completes the sections designated for him, which,  inquires about mood, behavioral symptoms, mental health history, risk assessment, physical symptoms, medical history, nutrition, social history, social support, quality of life, education history, education history, job history, alcohol/ substance use, habits, goals for treatment. The clinician is then able to review what the client has reported and use that information to guide further questioning.

Preceptor Evaluation

The interview assessment format my preceptor uses is one that is built into the computer system used at that facility so all assessments cover the necessary topics. The American Psychiatric Association released updated and revised guideline recommendations for the psychiatric evaluation of adults (Armstrong, 2016). These guidelines include nine areas of focus that complete a comprehensive psychiatric assessment for adults. The areas include history of present illness, psychiatric history, substance abuse history, medical history, review of systems, family history, person and social history, mental status exam, and impression and plan (APA, 2016). My preceptor’s assessments touch on all of these topics.

Most Helpful Information

I believe the most helpful information obtained during an assessment is the psychiatric history. From this section a clinician gathers information about client’s “psychiatric illnesses and their course over the client’s lifetime, including symptoms and treatment” (Sadock, Sadock, & Ruiz, 2016, p. 198). One should closely evaluate the types of psychiatric treatments attempted, effects of treatment, and client compliance with previous treatment (Sadock, Sadock, & Ruiz, 2016). This gives the clinician a bases upon which to recommend future treatments and interventions (Sarin, Jain, & Murthy, 2018).

References

American Psychiatric Association. (2016). Practice Guidelines for the Psychiatric Evaluation of

Adults (3rded) . Retrieved from

https://psychiatryonline.org/doi/pdf/10.1176/appi.books.9780890426760

Armstrong, C. (2016). APA Updates Guidelines on Psychiatric Evaluation in Adults. American

Family Physician, 94(1), 62–64. Retrieved from https://search-ebscohost-

com.ezp.waldenulibrary.org/login.aspx?direct=true&db=edswsc&AN=000378668900009&site=eds-live&scope=site

Northeast Georgia Physicians Group. (2019). Retrieved from

https://www.ngpg.org/fullpanel/uploads/files/ngpg-psychiatry-new-patient-forms-adult.pdf

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry:

Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.

Sarin, A., Jain, S., & Murthy, P. (2018). Turning the pages, or why history is important to

psychiatry. Indian journal of psychiatry60(Suppl 2), S174–S176. doi:10.4103/psychiatry.IndianJPsychiatry_429_17

POST 2

As a mental health provider, the advanced practice nurse will be tasked with evaluating new patient’s in inpatient and outpatient settings. The most important component of the initial evaluation of a mental health patient is the psychiatric interview (Sadock, Sadock, & Ruiz, 2014, p. 192). The psychiatric interview may contain many components which can include basic identifying information, chief complaints, psychosocial history, social history, medical assessment, and a mental status exam (MSE). The MSE is a key component of the psychiatric interview as it provides a description of the patient’s current mental status and helps to evaluate the patient’s behavior (Wheller, 2014, p. 102-3). I have developed a general interview format document that I can use to interview my patients. I have developed my interview guide from observing past preceptor’s interviews as well as academic resources. My current preceptors use a more informal process that they have developed over decades of practice. Having the organization of my interview format with the MSE at the end is the most useful part of my format since it allows me to observe the patient during the earlier sections of the interview to help decide which areas of the MSE to focus on at the end.

Interview Format Document

Patient name, date of birth, date of admission.

Legal Status: voluntary, involuntary, guardianship (name of guardian).

Referred by:

Primary language:

Chief complaints:

History of present illness:

Symptoms began:

Precipitating factors:

Psychosocial history:

Past psychiatric history:

Inpatient:

Outpatient:

Suicide attempts:

Drug/alcohol rehab:

Current Practitioners:

Psychiatrist:

Therapist:

PCP:

Past/present psychiatric medications (medication, dose, frequency, currently taking, last dose, side effects):

Family psychiatric history:

Maternal:

Paternal:

Siblings/offspring:

Other relatives:

Current substance use:

Cigarettes:

Alcohol/benzos:

Marijuana:

Heroin/opiates:

Methamphetamines:

Cocaine/crack:

Prescription drugs:

Other:

Clean and sober for:

Social history:

Work:

Employed: job type, employer

Unemployed, student, retired. Disabled

Financial status:

Education:

Family background:

Stable/unstable:

Religion/spiritual:

Living arrangements:

Relationship:

Children/siblings:

History of abuse:

Legal history:

Developmental factors:

Pregnancy:

Development:

Academic:

Behavioral:

Medical Assessment:

Vital signs:

Medical history—review of systems by exception:

Constitutional:

Respiratory:

Musculoskeletal:

Integumentary:

Neurological:

Eyes:

Genitourinary:

Immunologic:

Endocrine:

Ears/nose/mouth/throat:

Cardiac:

Gastrointestinal:

Hematologic/lymphatic:

Allergies:

Pain assessment:

Surgical history:

Strengths and weaknesses:

Family/social support:

Finances:

Coping skills:

Frustration tolerance:

Motivation for treatment:

Independent living skills:

Other:

Mental Status Exam

Appearance:

Attitude:

Activity:

Speech:

Mood:

Affect:

Symptoms:

Depression:

Mania:

Anxiety:

PTSD:

ADHD:

Sexual acting out:

Other:

Thought process:

Thought content:

Suicidal ideation:

Level of consciousness:

 

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