I.

Identifying Information

 Client Initials or Code: To maintain confidentiality.

 Age:
 Gender:
 Marital Status:
 Occupation:
 Educational Level:
 Date of Admission (if applicable):
 Source of Information: (e.g., client, family, medical records)
 Reliability of Information: Your assessment of how consistent and trustworthy the
information provided is.

II. Presenting Problem and Chief Complaint

 Client's Statement: In the client's own words, describe the primary reason they are
seeking help or were admitted.
 Brief Summary: A concise overview of the main issues and symptoms.

III. History of Present Illness (HPI)

 Onset and Evolution of Symptoms: When did the current problems begin? How have
they changed or progressed over time? Include specific details about the nature, severity,
frequency, and duration of symptoms.
 Precipitating Factors: What events or stressors might have contributed to the current
situation?
 Associated Symptoms: What other physical or psychological symptoms are present?
 Impact on Functioning: How have these symptoms affected the client's daily life,
including work, relationships, self-care, and social activities?
 Coping Mechanisms: What strategies has the client used to deal with these problems?
How effective have they been?
 Previous Psychiatric Treatment: Include dates, diagnoses, medications, therapies, and
outcomes.

IV. Past Psychiatric History

 Previous Diagnoses: List any past psychiatric diagnoses.

 Hospitalizations: Dates, reasons, and outcomes of any previous psychiatric
hospitalizations.
 Outpatient Treatment: Details of past therapy, counseling, or medication management.
 Medication History: List all past and present psychiatric medications, dosages, routes,
effectiveness, and side effects.
 History of Suicidal or Homicidal Ideation/Attempts: Include details about any past
thoughts, plans, or attempts, including intent, method, and circumstances.
 History of Self-Harm: Describe any history of non-suicidal self-injurious behavior.
V. Medical History

 Current Medical Conditions: List any current physical health problems.

 Past Medical History: Include significant past illnesses, surgeries, and injuries.
 Allergies: List any known allergies to medications, food, or other substances.
 Current Medications: List all current medications, including dosages and routes.
 Substance Use History: Detailed information about past and present use of alcohol,
tobacco, and illicit drugs, including frequency, amount, duration, and any history of
dependence or withdrawal.

VI. Family History

 Psychiatric History of Family Members: Note any family history of mental illness,
substance abuse, suicide, or other relevant issues. Include the relationship to the client.
 Family Dynamics and Relationships: Describe the client's family structure,
relationships with family members, and any significant family stressors or supports.

VII. Developmental History

 Early Childhood: Information about the client's early development, milestones, and any
significant childhood experiences.
 Education: Educational history, academic performance, and any learning difficulties.
 Social Development: Peer relationships, social skills, and involvement in social
activities.
 Occupational History: Work history, job stability, and satisfaction.
 Relationship History: Significant relationships, marital history, and current relationship
status.

VIII. Mental Status Examination (MSE)

 Appearance and Behavior: Describe the client's physical appearance, posture, eye
contact, motor activity, and any unusual mannerisms.
 Speech: Describe the rate, volume, tone, and clarity of speech.
 Mood and Affect:
o Mood: The client's subjective report of their prevailing emotional state (e.g., sad,
anxious, irritable). Use the client's own words if possible.
o Affect: The nurse's objective observation of the client's emotional expression
(e.g., congruent/incongruent with mood, range, intensity, stability).
 Thought Process: Describe the organization and flow of the client's thoughts (e.g.,
logical, linear, tangential, circumstantial, flight of ideas).
 Thought Content: Describe the content of the client's thoughts, including any delusions,
hallucinations, obsessions, compulsions, suicidal or homicidal ideation, or paranoia.
 Perception: Note any disturbances in perception, such as hallucinations (auditory, visual,
tactile, olfactory, gustatory) or illusions.
  Cognition: Assess orientation to person, place, time, and situation; attention and
concentration; memory (recent and remote); abstract thinking; and insight and judgment.
You might include results from brief cognitive screening tools if used.
 Insight: The client's awareness and understanding of their illness and the need for
treatment.
 Judgment: The client's ability to make sound and responsible decisions.

IX. Physical Assessment (Relevant Findings)

 Briefly describe any relevant physical findings from the nursing assessment or medical
examination that may be pertinent to the client's psychiatric condition or treatment.

X. Diagnostic Impression

 DSM-5 (or other relevant diagnostic system) Diagnosis(es): List the primary and any
secondary diagnoses, including the diagnostic codes. Include the rationale for each
diagnosis based on the information gathered.
 Differential Diagnoses: List other possible diagnoses that were considered and why they
were ruled out.

XI. Nursing Diagnoses

 Identify relevant nursing diagnoses based on the NANDA-I (or other relevant)
classification system. Prioritize the diagnoses based on the client's immediate needs and
safety.

XII. Goals of Treatment

 State short-term and long-term, measurable, achievable, realistic, and time-bound

(SMART) goals for the client's care. These should be developed collaboratively with the
client whenever possible.

XIII. Nursing Interventions

 Describe the specific nursing interventions implemented to address the identified nursing
diagnoses and achieve the treatment goals. Include:
o Therapeutic Communication: Specific techniques used.
o Medication Management: Administration, monitoring for side effects, and client
education.
o Milieu Therapy: Creating a safe and therapeutic environment.
o Psychoeducation: Providing information about the client's condition, treatment,
and coping strategies.
o Behavioral Interventions: Strategies used to modify maladaptive behaviors.
o Crisis Intervention: If applicable.
o Collaboration with other disciplines: (e.g., psychiatry, social work,
occupational therapy).
XIV. Evaluation

 Assess the client's progress toward achieving the stated goals. Describe the outcomes of
the nursing interventions and provide evidence to support your evaluation. Note any
changes in the client's condition or functioning.

XV. Discharge Planning (if applicable)

 Outline the plan for the client's discharge, including:

o Medication Management: Discharge medications and instructions.
o Follow-up Appointments: Referrals to outpatient therapy, psychiatry, support
groups, etc.
o Living Situation: Where the client will be residing after discharge.
o Support Systems: Identification of available support networks.
o Relapse Prevention Plan: Strategies to help the client manage symptoms and
prevent future episodes.

XVI. Recommendations

 Provide any further recommendations for the client's ongoing care or treatment.

Important Considerations for Psychiatric Nursing Case Studies:

 Confidentiality: Always protect the client's privacy by using initials or a code instead of
their full name.
 Objectivity: Strive to present information objectively and avoid personal biases or
judgments.
 Thoroughness: Gather and document comprehensive information to provide a holistic
view of the client.
 Therapeutic Relationship: Consider the impact of the nurse-client relationship on the
information gathered and the interventions implemented.
 Ethical Considerations: Be mindful of ethical principles such as autonomy, beneficence,
non-maleficence, and justice.
 Legal Considerations: Be aware of relevant legal and regulatory requirements related to
documentation and client care.