Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide.

Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide. Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Comprehensive psychiatric evaluation notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care. For this Assignment, you will document information about a patient that you examined in a group setting during the last 4 weeks, using the Comprehensive Psychiatric Evaluation Note Template provided.
Fill in the attach template, and please take a look at the example template that is attached because more instructions are given in the example. Any information that is not given, make it up or explain why that information is important. please include at least 4 apa sources no older than 5 years in the reflection part. Therapy Note: During the group therapy session, the client opened up about his feelings, saying, "I feel trapped in my own mind, like I can’t trust my thoughts, and it makes everything overwhelming." He shared a deep sense of isolation, expressing, "Sometimes I feel like I’m not really here, like I’m watching my life from afar." The focus of the session was on "Trauma Awareness," and the client bravely talked about the emotional toll of his trauma, especially the feelings of abandonment he experienced from his biological parents. He shared, "Not having them around makes me feel like I don’t belong anywhere," reflecting on how this absence has haunted him throughout his life. When he touched on his social withdrawal, he mentioned, "It's hard to reach out to others when I feel like I don’t deserve their attention." The client actively engaged with the other group members, discussing how trauma can show up in different symptoms and behaviors. He also mentioned the hallucinations he faces, describing them as "conversations that are not real but feel so vivid." As the group delved into grounding techniques, he expressed a wish to learn healthier ways to cope: "I want to learn how to deal with this noise in my head better." The session included psychoeducation about trauma and its effects, along with a structured discussion to encourage sharing and support among everyone. We introduced various types of trauma and prompted each member to think about how trauma affects their lives. The client seemed engaged, contributing to discussions and asking for clarification. We also used grounding exercises to help enhance present-moment awareness and create a sense of safety. I taught him techniques to manage distress, like focusing on his breathing and using sensory awareness to stay anchored in the present. The client appeared open to the strategies shared during the session, noting, "I think this grounding technique could help me when my thoughts start racing." Assessment: Chief Complaint / Presenting Problem: The client H.W presents with current symptoms of hallucinations, negative symptoms and disorganized speech for a period longer than 6 months. The client also has displayed an ongoing disturbance in interpersonal functioning. The client also presents depressed, diminished interest in or enjoyment of activities ,and. social withdrawal. Background History: H.W is a 42 year old African American male that resides in a Group Home. The client was born and raised in Hollywood, Fl by his maternal grandmother. Inpatient / Outpatient Psychiatric History & Patient's Response to Treatment: The client has previous history of psychiatric services. The client additionally reported that he has had ongoing services since a child. The client additionally reported a prior diagnosis of F20.9 Schizophrenia and Bipolar I Disorder. The client is currently under the care of a psychiatrist. Family Psychiatric History: The client denied any diagnosed maternal and/or paternal family history. Inpatient / Outpatient Substance Use History & Patient's Response to Treatment: The client denied any inpatient and/or outpatient substance use history. Family Substance Abuse History: The client denied any family substance abuse history. Physical Health History: The client is reportedly in good physical health and was last by his primary care doctor last year for a physical. The client denies any current health and/or previous health problems Developmental/Behavioural History: The client did not meet all developmental milestones to date during his childhood. The client noted that he struggled with communication, academically, and with socialization. The client additionally noted that he was placed in ESE classes throughout his academic career. The client noted that his grandmother noticed that his behavior was irregular when he was suspended from school excessively for masturbating in the open. The client additionally as an adult was observed looking in his neighbors window History of Abuse, Neglect and / or Abandonment: The client reported a history of abandonment from his biological parents. History of Domestic and / or Other Violent Behaviour: The client denied a history of domestic and/or violent behavior. Trauma History: The client reported not having his parents raise him resulted in him experiencing depression and feeling alone. Education History: The client reported his highest level of schooling was middle school where the client was expelled due to indecent exposure. Employment / Military History: The client denied any employment and/or military history. Legal History: The client denied any legal involvement. (Physical Appearance) Appropriate (Eye Contact) Normal (Motor Activity) WNL (Behavior Rapport) Easily Established (Oriented To) Time (Oriented To) Place (Oriented To) Person (Oriented To) Situation (Speech) Normal Rate (Affect) Normal (Mood) Anxious (Memory) Intact (Sleep) Difficulty Falling Asleep Sleep Problems: The client reports inability to sleep. (Hallucinations) Auditory Hallucinations Describe: the client reports frequent conversations in his head. (Delusions) None Reported (Thought Process) Circumstantial (Thought Content) Intact/WNL (Insight Judgement) Fair (Impulse Control) Fair (Interaction) Guarded School / Work Insights: The client noted that during school he struggled with making friends. The client denies ever being employed. Personal Relationships: The client denies any personal relationships. Father Involved, Present or Absent (If so, describe relationship): The client's father is not present in his life. Mother Involved, Present or Absent (If so, describe relationship): The client's mother is not present in his life. Number of Childrens: 0 Other Family Relationships: The client is close to his maternal grandmother. The client additionally has siblings that he communicates with. Social Relationships (Peers / Friends): The client has friends at his group home . Psychological / Personal Functioning (Current Symptoms): the client presents with current symptoms of hallucinations, negative symptoms and disorganized speech for a period longer than 6 months. The client also has displayed an ongoing disturbance in interpersonal functioning. The client also presents depressed, diminished interest in or enjoyment of activities ,and. social withdrawal. Personal resources and strengths (including the availability & use of family and peers): The clients family and group home are his personal resources. Problems with primary support group (Last Year) Problems related to the social environment (Last Year) Economic problems (Last Year) (Risk Suicide - Behaviours) None (Risk Homocide - Behaviours) None (Risk Compliance - Assessed) Full Compliance (Risk Substance) None or Normal Use (Risk Sexual Abuse - Assessment) Yes, Abuse or / and Sexual Abuse Present. (Risk Sexual Abuse) Not Legally Reportable (Elder Abuse - Assessment) No, client does not suffer from Abuse or Sexual Abuse. Risk to Community as Criminal: The client is not a risk to the community