| Course | D344 The Assessment and Diagnostic Process of Psychiatric Nurse Practitioner Practice |
|---|---|
| Task | Task 1 |
| Paper type | Psychiatric evaluation write-up |
| Length | About 800 words, 4 pages |
| Format | APA 7 |
| School | Western Governors University (WGU) |
| Program | MSN Psychiatric Mental Health Nurse Practitioner |
| Updated | September 2026 |
Free sample paper for D344 Task 1
Psychiatric Evaluation Write-Up: A 29-Year-Old Paralegal Referred for Lifelong Trouble Focusing
Student Name
Leavitt School of Health, Western Governors University
D344: The Assessment and Diagnostic Process of Psychiatric Nurse Practitioners, Task 1
Course Instructor
Month Day, Year
Psychiatric Evaluation Write-Up: A 29-Year-Old Paralegal Referred for Lifelong Trouble Focusing
Identifying Information and Referral
The patient is a composite 29-year-old single woman who works as a paralegal at a mid-sized law firm. She was referred by her primary care nurse practitioner for evaluation of 'possible ADHD' after she described trouble finishing work, missed deadlines and a recent written warning. She attended the 75-minute evaluation alone and gave consent to speak with her mother by phone for childhood history.
Chief Concern
In her words: "I have always been the smart one who can't get anything done on time. Now it might cost me my job."
History of Present Illness
She reports difficulty sustaining attention on long documents, losing her place, making careless errors in citations, forgetting tasks unless written down, misplacing keys and her badge several times a week and avoiding tasks that require long mental effort until a deadline forces her. She describes her mind as 'a radio flipping stations.' She reports that these problems have been present 'as long as I can remember' and worsened two years ago when she moved from a structured role to one with several attorneys assigning work. She denies restlessness that makes her leave her seat, but reports fidgeting and interrupting others in meetings. On the Adult ADHD Self-Report Scale, a screening tool whose first six items are most predictive (Kessler et al., 2005), she endorsed five of the six screener items in the positive range.
Mood: she describes frustration and 'feeling like a failure' after the warning, but denies persistent low mood, loss of interest, change in appetite or thoughts of death. Anxiety: she worries about work performance but not about many areas of life, and the worry follows the missed deadlines rather than preceding them. Sleep: she goes to bed at midnight, sleeps about seven hours, denies snoring or witnessed apneas and wakes rested on weekends. She denies ever having days-long spells of unusually high mood, needing little sleep without tiring, or spending sprees.
Collateral History
Her mother, by phone with the patient's consent, reports that teachers in elementary school described her as 'daydreaming' and 'not living up to her potential,' that homework took hours with constant reminders and that she lost jackets and lunch boxes 'constantly.' Report cards from third and fifth grade, which the patient brought, include teacher comments about incomplete work and needing redirection. No behavior problems or school discipline were reported.
Past Psychiatric, Medical, Substance and Social History
Psychiatric: no prior diagnoses, treatment, hospitalizations or suicide attempts. Medical: seasonal allergies; normal thyroid function tests at her annual visit three months ago; no head injury, seizures or cardiac history. Medications: cetirizine as needed. Substances: drinks two glasses of wine on weekends; no cannabis or other drugs; three cups of coffee daily. Family: father 'never finished anything,' not formally diagnosed; maternal aunt treated for depression. Social: completed a bachelor's degree in six years after changing majors twice; lives alone; has a supportive partner; no legal history. Development: normal milestones by mother's report.
Mental Status Examination
Appearance: well groomed, casually dressed, appears stated age. Behavior: cooperative and engaged; shifted position frequently and tapped a pen through much of the interview; looked at her phone twice when it vibrated and apologized. Speech: normal rate and volume, occasionally interrupted the examiner mid-question. Mood (her word): 'stressed.' Affect: mildly anxious, full range, congruent with content, brightened when discussing her partner. Thought process: linear and goal directed, with occasional tangents that she corrected herself. Thought content: preoccupied with job security; no suicidal or homicidal ideation, no delusions or obsessions. Perceptions: no hallucinations reported or observed. Cognition: alert and fully oriented; recalled three of three words immediately and two of three at five minutes; serial sevens with two errors, self-corrected once. Insight: good; she recognizes a long-standing pattern. Judgment: good; sought evaluation before losing her job.
Risk Assessment
She denies current or past suicidal ideation, plans or attempts, self-harm and thoughts of harming others. There are no firearms in her home. Protective factors include her relationship, her insight and her motivation to keep her job. Risk of harm to self or others is assessed as low, and she was given the clinic's after-hours number. The work warning is a significant stressor, and the risk assessment will be repeated at the next visit.
Summary of Findings
Recorded findings relevant to diagnosis: long-standing inattention and disorganization reported by the patient and corroborated by her mother and by childhood report cards; current impairment at work; some hyperactive and impulsive features observed during the interview; a positive adult ADHD screener; no evidence of a mood episode, generalized anxiety pattern, psychotic symptoms, sleep disorder or substance misuse; normal recent thyroid tests. These findings are carried into the diagnostic formulation, where diagnostic criteria (American Psychiatric Association, 2022) are applied and alternatives weighed against current consensus on adult diagnosis (Faraone et al., 2021).
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
Faraone, S. V., Banaschewski, T., Coghill, D., Zheng, Y., Biederman, J., Bellgrove, M. A., Newcorn, J. H., Gignac, M., Al Saud, N. M., Manor, I., Rohde, L. A., Yang, L., Cortese, S., Almagor, D., Stein, M. A., Albatti, T. H., Aljoudi, H. F., Alqahtani, M. M. J., Asherson, P., . . . Wang, Y. (2021). The World Federation of ADHD international consensus statement: 208 evidence-based conclusions about the disorder. Neuroscience and Biobehavioral Reviews, 128, 789-818. https://doi.org/10.1016/j.neubiorev.2021.01.022
Kessler, R. C., Adler, L., Ames, M., Demler, O., Faraone, S., Hiripi, E., Howes, M. J., Jin, R., Secnik, K., Spencer, T., Ustun, T. B., & Walters, E. E. (2005). The World Health Organization Adult ADHD Self-Report Scale (ASRS): A short screening scale for use in the general population. Psychological Medicine, 35(2), 245-256. https://doi.org/10.1017/S0033291704002892
What the D344 Task 1 instructions ask
The first D344 task asks you to document a comprehensive psychiatric evaluation. Most versions ask for identifying information and referral source, chief concern, history of present illness, past psychiatric, medical, substance, family and social history, a mental status examination, a risk assessment and a summary of findings. Some versions stop before the diagnosis, which comes in Task 2. The patient may be composite or drawn from clinical practice with details removed. Evaluators look for a history that gathers the information a diagnosis will need, including collateral sources, a mental status examination that covers every domain with observed detail, and a risk assessment that states risk and protective factors clearly. Many versions also ask for screening instruments and their scores.
How this D344 Task 1 example is built
The write-up follows the standard order of a psychiatric evaluation. The chief concern is quoted, then the history of present illness describes symptoms with examples and their effect on work. Collateral history from the mother adds childhood observations, which matter for this presentation. Each history section is concise but complete. The mental status examination covers appearance, behavior, speech, mood, affect, thought process and content, perception, cognition, insight and judgment, with observations rather than labels. The risk assessment names ideation, plans, means and protective factors. The summary lists the findings relevant to diagnosis without yet naming one, leaving that for the formulation in Task 2. Collateral history is labeled as collateral so its source is never unclear.
Where the D344 Task 1 rubric puts the marks
D344 Task 1 aspects are each rated competent, approaching competence or not evident. History aspects check for completeness and relevance, including collateral information where available. A mental status aspect looks for every domain documented with specific observations. A risk aspect rewards a clear assessment of suicide and violence risk with protective factors. A summary aspect asks for findings organized for diagnosis. Evaluators pay attention to professional language, avoiding judgmental terms, and to consistency between the history and the examination. Screening tools, where used, should be named and scored, and diagnostic references should be current. Evaluators check that the history and the mental status findings agree, and that any screening tool is named with its score and cutoff. A summary that gathers findings under diagnostic headings shows the evaluation was organized for the next step.
D344 Task 1 help: what sends it back
Psychiatric evaluations come back most often when the mental status examination uses labels instead of observations. Write that she tapped a pen throughout rather than that she was restless. Second, collateral history is missing for conditions where childhood onset matters. Include it when you can, with consent. Third, substance history is thin. Ask about quantity, frequency and consequences. Fourth, risk assessments state low risk without the evidence. List risk and protective factors. Finally, keep the summary diagnostic in purpose. It should gather the findings the formulation will use, not repeat the whole history. Record the date and source of any collateral report.
Get a D344 Task 1 example written to your instructions
Send the D344 Task 1 instructions and rubric aspects from your course of study, plus any patient details the task specifies or the parameters you were given. We build a composite example to those aspects, documented the way a psychiatric record is documented, and return it in 24-48h. The first custom sample is free.
More D344 papers
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- D347 Task 1 Developmental Assessment
- D346 Task 2 Care Transition Plan
- D120 Task 1 Population Risk Analysis
- D118 Task 2 Adult Management Plan
D344 Task 1 questions, answered
Can the evaluation be based on a patient I saw in clinical?
Only as a composite, and only if your instructions permit it. Setting, ages, dates and identifying circumstances have to change enough that the person cannot be recognized, which is why every patient in our examples is assembled rather than reported. Your placement documentation stays where it belongs, in the clinical record you keep for your own hours.
How detailed does the mental status examination need to be?
Detailed enough that a clinician who was not present could picture the encounter. Every domain gets an entry, and the entries describe observation rather than summary, since an aspect asking for a complete examination is checking coverage as well as quality. Empty domains and one-word entries are the most common reason this section comes back.
Should the write-up include a diagnosis?
Follow the task instructions, which in current versions often keep the diagnostic argument for the second task and ask this one for assessment and findings. Where a working impression is requested, state it as provisional and tie it to the findings already recorded. Announcing a diagnosis the write-up has not evidenced weakens the aspects this task is actually judged on.
How detailed does the D344 mental status examination need to be?
Every domain should be documented with observed detail, from appearance and behavior to insight and judgment. The sample records specific observations, such as pen tapping, rather than one-word labels.
Where can I find a free D344 Task 1 sample paper?
The complete psychiatric evaluation write-up appears above with notes. Share your D344 task and case, and the first tailored evaluation is written for you at no cost.