Final Case Formulation

Instructions

Select a pediatric/adolescent client or case that you have worked with either in your current nursing practice or your PMHNP student clinical setting. Ensure that you correctly remove the appropriate information (name, etc.) to remain HIPAA compliant.

Prepare a full mental health evaluation on your pediatric/adolescent client. Use the resources presented in the course to help guide your evaluation. Kaplan & Saddock’s Synopsis of Psychiatry has a robust list of the categories of information you should collect and present in your evaluation report (5.1. Parts of the Initial Psychiatric Interview). This should include the following:

A full psychiatric, physical, social, family, and birth and developmental history including verbal reports of the client, your observations of the client, and a summary of any diagnostic aids that you have used.

The use of at least one psychiatric screening or assessment tool from the literature to assist in your assessment of the client

A full physical assessment in addition to the mental status exam and psychiatric history

Develop a DSM-5 diagnostic assessment:

Support your diagnosis through a thoughtful, evidence-based rationale of the data collected in your evaluation.

Propose a practical, evidence-based plan of care:

Keep in mind the role of the psychiatric-mental health nurse practitioner is to assess all aspects of the patient’s health status, including health promotion, and disease prevention. Psychiatric care is interdisciplinary. Your plan of care may include the use of other mental health professionals for the delivery of appropriate care. For example, someone who has chronic back pain, and has been out of work may have these factors contributing to his or her depression and may require a pain specialist and social services to address that aspect of the client’s poor psychological functioning.

Requirements

Support your assessment, diagnosis, treatment, and management plan with appropriate literature citations.

The SOAP note should be no more than ten pages in length, not including the title and reference pages.

Use current APA formatting and citations.

Acronyms should not be used.

The assessment must be well written and be of professional quality. It must be clear, and well developed, free of spelling, grammatical, and syntactical errors, and in full sentences format.