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  • Subjective: What details did the patient provide regarding  their chief complaint and symptomology to derive your differential  diagnosis? What is the duration and severity of their symptoms? How are  their symptoms impacting their functioning in life?
  • Objective: What observations did you make during the psychiatric assessment? 
  • Assessment: Discuss their mental status examination results.  What were your differential diagnoses? Provide a minimum of three  possible diagnoses and why you chose them. List them from highest  priority to lowest priority. What was your primary diagnosis and why?  Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.
  • Plan: What was your plan for psychotherapy? What was your  plan for treatment and management, including alternative therapies?  Include pharmacologic and nonpharmacologic treatments, alternative  therapies, and follow-up parameters, as well as a rationale for this  treatment and management plan. Also be sure to include at least one  health promotion activity and one patient education strategy.
  • Reflection notes: What would you do differently with this  patient if you could conduct the session again? If you are able to  follow up with your patient, explain whether these interventions were  successful and why or why not. If you were not able to conduct a follow  up, discuss what your next intervention would be.