Instructions: Students will choose one clinical patient upon which they will do a Brief Psychiatric Assessment and a Geriatric Functional Assessment.
Begin write up with – describing the patient’s demographic data (age, children, family structure, etc.) No patient identifiers should be submitted.
End write up with: A brief summary of your findings (this is usually titled Impression)
Transcribe to Docucare.
• Describe how you demonstrated the QSEN competency of safety (is environment safe for the pt?) describing the cognitive and physical limits of human performance (If pt is elderly, is pt able to answer the questions? Do they appear to have dementia? Did they get fatigued easily?)
• Identify patient’s unique concerns, priority for care, and summarize what you think pt needs in your clinical judgment.
• Reflect on the interview, communication techniques, and circumstances that hindered or facilitated the interview.
• Please see grading rubric on next page
Brief Psychiatric Assessment
1. General Appearance, Behavior and Speech Patterns -Is patient dressed and groomed appropriately for the situation? Is eye contact appropriate for culture? Any unusual body movements? Are they restless? Is their speech of normal rate and rhythm?
2. Mood & Affect –What is patients’ mood? Ask patient how they have been feeling, are they sad? If they say yes, ask what is bothering them? Mood can be described as – euthymic, depressed, labile, hyperactive/manic
3. Thought Content and Process – Is the patient able to speak in a logical manner, do they stay on topic? Do they seem confused? Do they appear delusional (are they talking about things that are not real)? Do they appear to have dementia or delirium? Ask – Does the patient have any thoughts of self-harm or suicide; do they express desire to be with deceased husband or child?
4. Sensorium/Cognition and Orientation – Ask – Does pt know where they are? Date, Name?
5. Judgment and Insight – ask the patient if they where in NYC and missed the bus how would they get home?
6. Reliability – Do you feel patient is reliable in their answers to the above questions
The patient is a 79 y old female whose admitting diagnosis is Alzheimer’s disease. She like to be called Flo. Married to husband mike for 57 years. Grew up in sunny side queens. Worked as a secretary at SCO foster care agency for 30 years. She loves singing, arts and crafts. She responds best with hearing aids in. She had dementia with psychosis anxiety and paranoia. She is alert and oriented x 2. Irritable affect on and off. No suicidal ideations. Suspicious of staff with paranoua . She has poor st memory. Impaired impulse control. No agitation or aggression.
Include a sentence from the journal tying into the patients situation using apa format
