realistic case study and include appropriate and pertinent clinical information that will cover the following:
- Subjective data:
- Chief Complaint
- History of the Present Illness (HPI) includes the presenting problem and the 8 dimensions of the problem. See an example of the correct way to document the psychiatric HPI here. (Links to an external site.)
- Review of Systems (ROS)
- Elaborate on this data if it was not provided in the discussion post assignment.
- Objective data:
- Medications
- Allergies
- Past medical history
- Past psychiatric history
- Family psychiatric history
- Past surgical history
- Social history
- Labs and Screening tools
- Vital signs
- Elaborate on this data if it was not provided in the discussion post assignment.
- Assessment:
- Primary Diagnosis-DSM5 only
- Differential diagnosis-DSM5 only
- Plan:
- Pharmacologic treatment plan
- Non-pharmacologic treatment plan
- Follow up plan
- Other:
- Incorporation of current clinical guidelines
- Integration of research articles
- Role of the Nurse practitioner
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