Identifying data, but only use the individual’s initialsChief Complaint (CC)History of Present Illness (HPI)Psychiatric History and Substance Use

Use of APA 7th edition format and grammar

Identifying data, but only use the individual’s initials

Chief Complaint (CC)

History of Present Illness (HPI)

Psychiatric History and Substance Use History

Personal and Social History

Mental Status Examination

Suicide and Homicide Assessment

Medical History

Allergies

Current Medications

Review of Systems

History of Abuse, Neglect, and Trauma

Mental Status Examination

Assessment i.e. DSM 5-TR Diagnosis

Nursing Theory/Psychodynamic Approach

Treatment Plan and Goals

Education and Referrals

Conclusions and Summary

References page including evidenced-based data

      • Note: TurnItIn will be linked with this assignment
      • Topic: anxiety
      •  (The medical case must be of a patient diagnosed with anxiety)