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Comprehensive Evaluation

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Document the following for the family in the video, using the Comprehensive Evaluation Note Template: 

  • Chief complaint
  • History of present illness
  • Past psychiatric history
  • Substance use history
  • Family psychiatric/substance use history
  • Psychosocial history/Developmental history
  • Medical history
  • Review of systems (ROS)
  • Physical assessment (if applicable)
  • Mental status exam
  • Differential diagnosis—Include a minimum of three differential diagnoses and include how you derived each diagnosis in accordance with DSM-5-TR diagnostic criteria
  • Case formulation and treatment plan
  • Include a psychotherapy genogram for the family

Note: For any item you are unable to address from the video, explain how you would gather this information and why it is important for diagnosis and treatment planning. 

 

Transcript/abstract of the video, exemplar/template are attached below

 
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