Comprehensive Psychiatric Evaluation Note and Patient Case Presentation

Assignment 2: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation

 

Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. 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 at your practicum site, using the Comprehensive Psychiatric Evaluation Note Template provided. You will then use this note to develop and record a case presentation for this patient. 

To Prepare

• Review this week’s Learning Resources and consider the insights they provide about impulse-control and conduct disorders. 
• Select a patient for whom you conducted psychotherapy for an impulse control or conduct disorder during the last 6 weeks. 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. All psychiatric evaluation notes must be signed, and each page must be initialed by your Preceptor. When you submit your note, you should include the complete comprehensive evaluation note as a Word document and pdf/images of each page that is initialed and signed by your Preceptor. You must submit your note using SafeAssign. Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Grading Policy.
• Then, based on your evaluation of this patient, develop a video presentation of the case. Plan your presentation using the Assignment rubric and rehearse what you plan to say. Be sure to review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
• Include at least five scholarly resources to support your assessment and diagnostic reasoning.
• Ensure that you have the appropriate lighting and equipment to record the presentation.

The Assignment

Record yourself presenting the complex case for your clinical patient.

Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video. 

In your presentation:

• Dress professionally and present yourself in a professional manner.  
• Display your photo ID at the start of the video when you introduce yourself.
• Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information). 
• Present the full complex case study. Be succinct in your presentation, and do not exceed 8 minutes. Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.
  • Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What was 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 the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms. 
  • Plan: Describe your treatment modality and your plan for psychotherapy. Explain the principles of psychotherapy that underline your chosen treatment plan to support your rationale for the chosen psychotherapy framework. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this psychotherapy session?
  • Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.

By Day 7

Submit your Video and Comprehensive Psychiatric Evaluation Note Assignment. You must submit two files for the evaluation note, including a Word document and scanned pdf/images of each page that is initialed and signed by your Preceptor.

Kleptomania——–are impulse control disorders, which are psychiatric conditions characterized by the inability to resist an impulsive action that can lead to harmful results. People suffering from these disorders experience a feeling of increased anxietyprior to committing the action. Once the action is completed, patientsfeel relief in spite of the potentially dangerous consequences. Treatment includes psychotherapyand some medications.

 

 

CASEREPRESENTATIONS

This is 26 years Native American Female who presented today with her boyfriend for continuous therapy and treatments. She is Alert and oriented. Kept on falling asleep in middle of the evaluation but was able to answer all questions. She has history of overdosing herself when frustrated. Her right arm and part of right thigh with scratches from self inflicting cuts to harm self. 4 days ago she overdosed self with fentanal which she bought at the street as a street drug and was taken to hospital where she was stabilized and send home. She lives with her boyfriend who they have been together for 8 years. The boyfriend has been assigned top care for her and he says her stress and anxiety is increasing when she speaks to her dad. He says anytime she talks with the father they argue then her anxiety is increase, then after that according to her boyfriend she has so much anxiety that cant control self, so she does “stupid things”. She has tried overdose many times. He mom died of drug overdose and so as her grandfather. Her father re-married but the father and her wife are all in drugs, She has no any siblings and no kids. She did not complete high school, dropped at 11th grade because of continuous being in trouble because of using drugs (weed)

She has a history of ,Depression, unspecified, Attention-deficit hyperactivity disorder, unspecified type, Anxiety disorder, unspecified, Opioid dependence, uncomplicated, Kleptomania when anxous

 

 

She denies any illicit drugs despite a uds showing different. Patient warned about use of fentanyl, lyrica and cocaine. She agreed to try to comply with all the teaching and warning

 

Today she denies HI or SI and contracted for safety. 

 

We agreed he will not miss his weekly F/U next week, He will call the office if he has no ride, he will not take any street drugs or any unsubscribed medication, he will take his medication as prescribed and if any emergency or symptoms of withdrawal he will call the help line immediately, then we will meet next week for evaluation.

 

Medications

• Buprenorphine HCl-Naloxone HCl Dihydrate (Suboxone) 8-2 MG Sublingual Film 1Strip sl BID

 

• Gabapentin (Neurontin) 800 MG Oral Tablet by mouth 3 times a day for lower back pain unspecified,
•  
• Lisdexamfetamine Dimesylate (Vyvanse) 40 MG Oral Capsule one ca[psule by mouth in the morning
•  
• Sertraline HCl (Zoloft) 50 MG Oral Tablet by mouth daily

 

 

 

 

 

Rubric Detail

 

Select Grid View or List View to change the rubric’s layout.

 

Name: PRAC_6645_Week7_Assignment2_Rubric

• Grid View
• List View

 

Excellent

Good

Fair

Poor

Photo ID display and professional attire

5 (5%) – 5 (5%)

Photo ID is displayed. The student is dressed professionally.

0 (0%) – 0 (0%)

0 (0%) – 0 (0%)

0 (0%) – 0 (0%)

Photo ID is not displayed. Student must remedy this before grade is posted. The student is not dressed professionally.

Time

5 (5%) – 5 (5%)

The video does not exceed the 8-minute time limit.

0 (0%) – 0 (0%)

0 (0%) – 0 (0%)

0 (0%) – 3 (3%)

The video exceeds the 8-minute time limit. (Note: Information presented after 8 minutes will not be evaluated for grade inclusion.)

Discuss Subjective data: • Chief complaint • History of present illness (HPI) • Medications • Psychotherapy or previous psychiatric diagnosis • Pertinent histories and/or ROS

9 (9%) – 10 (10%)

The video accurately and concisely presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis.

8 (8%) – 8 (8%)

The video accurately presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis.

7 (7%) – 7 (7%)

The video presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis, but is somewhat vague or contains minor inaccuracies.

0 (0%) – 6 (6%)

The video presents an incomplete, inaccurate, or unnecessarily detailed/verbose description of the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis. Or subjective documentation is missing.

Discuss Objective data: • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history • Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses

9 (9%) – 10 (10%)

The video accurately and concisely documents the patient’s physical exam for pertinent systems. Pertinent diagnostic tests and their results are documented, as applicable.

8 (8%) – 8 (8%)

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are documented, as applicable.

7 (7%) – 7 (7%)

Documentation of the patient’s physical exam is somewhat vague or contains minor inaccuracies. Diagnostic tests and their results are documented but contain inaccuracies.

0 (0%) – 6 (6%)

The response provides incomplete, inaccurate, or unnecessarily detailed/verbose documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or objective documentation is missing.

Discuss results of Assessment: • Results of the mental status examination • Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.

18 (18%) – 20 (20%)

The video accurately documents the results of the mental status exam. Video presents at least three differentials in order of priority for a differential diagnosis of the patient, and a rationale for their selection. Response justifies the primary diagnosis and how it aligns with DSM-5 criteria.

16 (16%) – 17 (17%)

The video adequately documents the results of the mental status exam. Video presents three differentials for the patient and a rationale for their selection. Response adequately justifies the primary diagnosis and how it aligns with DSM-5 criteria.

14 (14%) – 15 (15%)

The video presents the results of the mental status exam, with some vagueness or inaccuracy. Video presents three differentials for the patient and a rationale for their selection. Response somewhat vaguely justifies the primary diagnosis and how it aligns with DSM-5 criteria.

0 (0%) – 13 (13%)

The response provides an incomplete, inaccurate, or unnecessarily detailed/verbose description of the results of the mental status exam and explanation of the differential diagnoses. Or assessment documentation is missing.

Discuss treatment Plan: • A treatment plan for the patient that addresses psychotherapy and rationales including a plan for follow-up parameters and referrals

18 (18%) – 20 (20%)

The video clearly and concisely outlines an evidence-based treatment plan for the patient that addresses treatment modality, psychotherapy choice with framework principles, and rationale. Discussion includes a clear and concise follow-up plan and parameters. The discussion includes a clear and concise referral plan.

16 (16%) – 17 (17%)

The video clearly outlines an appropriate treatment plan without evidence-based discussion for the patient that addresses treatment modality, psychotherapy choice with framework principles, and rationale. Discussion includes a clear follow-up plan and parameters. The discussion includes a clear referral plan.

14 (14%) – 15 (15%)

The response somewhat vaguely or inaccurately outlines a treatment plan for the patient and provides a rationale for the treatment approaches recommended. The discussion is somewhat vague or inaccurate regarding the follow-up plan and parameters. The discussion is somewhat vague or inaccurate regarding a referral plan.

0 (0%) – 13 (13%)

The response does not address the treatment plan or the treatment plan is not appropriate for the assessment and the diagnosis or is missing elements of the treatment plan. There is no discussion for follow-up and parameters. There is no discussion of a referral plan.

Reflections on this case.

5 (5%) – 5 (5%)

Reflections are thorough, thoughtful, and demonstrate critical thinking. Reflections contain all 3 elements from the assignment directions including a discussion demonstrating critical thinking of the case related to the HealthyPeople 2030 social health determinates. Clearly and concisely relates discussion to the psychiatric and mental health field.

4 (4%) – 4 (4%)

Reflections demonstrate critical thinking. Reflections demonstrate critical thinking. Reflections contain 2 of the elements from the assignment directions with one being a basic discussion of the case related to the HealthyPeople 2030 social health determinates. Clearly relates discussion to the psychiatric and mental health field.

3.5 (3.5%) – 3.5 (3.5%)

Reflections are somewhat general or do not demonstrate critical thinking. Reflections contain 1 of the required elements from the assignment directions which is the HealthyPeople 2030 social health determinates. Somewhat vaguely or inaccurately relates discussion to the psychiatric and mental health field.

0 (0%) – 3 (3%)

Reflections are incomplete, inaccurate, or missing. There are no Reflections elements from the assignment directions (no HeathlyPeople 2030 social health determinates, no health promotion, and no education activity). Missing discussion relating to the psychiatric and mental health field or relates discussion to another specialty realm including medical co-morbidity illnesses.

Comprehensive Psychiatric Evaluation documentation

18 (18%) – 20 (20%)

The response clearly, accurately, and thoroughly follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.

16 (16%) – 17 (17%)

The response accurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.

14 (14%) – 15 (15%)

The response follows the Comprehensive Psychiatric Evaluation format to document the selected patient case, with some vagueness and inaccuracy.

0 (0%) – 13 (13%)

The response incompletely and inaccurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.

Presentation style

5 (5%) – 5 (5%)

Presentation style is exceptionally clear, professional, and focused.

4 (4%) – 4 (4%)

Presentation style is clear, professional, and focused.

3.5 (3.5%) – 3.5 (3.5%)

Presentation style is mostly clear, professional, and focused.

0 (0%) – 2 (2%)

Presentation style is unclear, unprofessional, and/or unfocused.

 

Total Points: 100

Name: PRAC_6645_Week7_Assignment2_Rubric

 

 

Please Check The last one . I scored a bad great and these were the mistakes. Also We don’t do any labs in the clinic which am at. So for labs just say unable to do.

Use the tablets

NRNP/PRAC 6645 Comprehensive Psychiatric 

Evaluation Note Template

 

INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY

If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignments. After reviewing full details of the rubric, you can use it as a guide.

In the Subjective section, provide:

• Chief complaint
• History of present illness (HPI)
• Past psychiatric history
• Medication trials and current medications
• Psychotherapy or previous psychiatric diagnosis
• Pertinent substance use, family psychiatric/substance use, social, and medical history
• Allergies
• ROS
• Read rating descriptions to see the grading standards! 

In the Objective section, provide:

• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses. 
• Read rating descriptions to see the grading standards! 

In the Assessment section, provide:

• Results of the mental status examination, presented in paragraph form.
• At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
• Read rating descriptions to see the grading standards!

Reflect on this case. Include what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.). 

(The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.) 

EXEMPLAR BEGINS HERE

CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why they are presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member. 

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication, and referral reason. For example:

N.M. is a 34-year-old Asian male who presents for psychotherapeutic evaluation for anxiety. He is currently prescribed sertraline by (?) which he finds ineffective. His PCP referred him for evaluation and treatment.

Or

P.H. is a 16-year-old Hispanic female who presents for psychotherapeutic evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her mental health provider for evaluation and treatment.

Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. 

Paint a picture of what is wrong with the patient. This section contains the symptoms that is bringing the patient into your office. The symptoms onset, the duration, the frequency, the severity, and the impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders. You will complete a psychiatric ROS to rule out other psychiatric illnesses. 

Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP. 

General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13.

Caregivers are listed if applicable.

Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors?

Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it)

Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. (Or, you could document both.)

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures. 

Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information (be sure to include a reader’s key to your genogram) or write up in narrative form. 

Psychosocial History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology. However, at a minimum, please include: 

• Where patient was born, who raised the patient
• Number of brothers/sisters (what order is the patient within siblings)
• Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children?
• Educational Level
• Hobbies
• Work History: currently working/profession, disabled, unemployed, retired?
• Legal history: past hx, any current issues?
• Trauma history: Any childhood or adult history of trauma?
• Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)

 

Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries. 

 

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

Assessment

Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudo hallucinations, illusions, etc.), cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form. 

He is an 8 yo African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking.   He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good. 

Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s treatment of the patient and why or why not. What did you learn from this case? What would you do differently? 

Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

Case Formulation and Treatment Plan.  

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions with psychotherapy, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. *see an example below—you will modify to your practice so there may be information excluded/included—what does your preceptor document?

Example:

Initiation of (what form/type) of individual, group, or family psychotherapy and frequency.

Documentation of any resources you provide for patient education or coping/relaxation skills, homework for next appointment.

Client has emergency numbers: Emergency Services 911, the Client’s Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)

 

Reviewed hospital records/therapist records for collaborative information; Reviewed PCP report (only if actually available)

 

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (This relates to informed consent; you will need to assess their understanding and agreement.)

 

Follow up with PCP as needed and/or for:

 

Write out what psychotherapy testing or screening ordered/conducted, rationale for ordering

 

Any other community or provider referrals 

 

Return to clinic: 

 

Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care OR if one-time evaluation, say so and any other follow up plans.

References (move to begin on next page)

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

 

 

 

 

 

 

 

Rubric Detail

 

A rubric lists grading criteria that instructors use to evaluate student work. Your instructor linked a rubric to this item and made it available to you. Select Grid View or List View to change the rubric’s layout.

 

Name: PRAC_6645_Week4_Assignment2_Rubric

 

 

• Grid View
• List View

 

Excellent

Good

Fair

Poor

Photo ID display and professional attire

5 (5.00%) – 5 (5.00%)

Photo ID is displayed. The student is dressed professionally.

0 (0.00%)

0 (0.00%) – 0 (0.00%)

Feedback:

Show your badge to the camera please. A cluttered room is not a professional place for your video presentations.

0 (0.00%) – 0 (0.00%)

0 (0.00%) – 0 (0.00%)

Photo ID is not displayed. Student must remedy this before grade is posted. The student is not dressed professionally.

Time

5 (5.00%)

5 (5.00%) – 5 (5.00%)

The video does not exceed the 8-minute time limit.

Feedback:

Keep it to no more than 8 minutes for full point value in the future.

0 (0.00%) – 0 (0.00%)

0 (0.00%) – 0 (0.00%)

0 (0.00%) – 3 (3.00%)

The video exceeds the 8-minute time limit. (Note: Information presented after 8 minutes will not be evaluated for grade inclusion.)

Discuss Subjective data: • Chief complaint • History of present illness (HPI) • Medications • Psychotherapy or previous psychiatric diagnosis • Pertinent histories and/or ROS

9 (9.00%) – 10 (10.00%)

The video accurately and concisely presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis.

8 (8.00%) – 8 (8.00%)

The video accurately presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis.

7 (7.00%)

7 (7.00%) – 7 (7.00%)

The video presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis, but is somewhat vague or contains minor inaccuracies.

Feedback:

Be careful with medications. Naloxone is for emergency use only for opioid overdose, not daily as you indicated. The reference you used was for a different medication. Why does he take meloxicam? Why would you prescribe him medication for drug abuse when he hasn’t told you he is currently using drugs?

0 (0.00%) – 6 (6.00%)

The video presents an incomplete, inaccurate, or unnecessarily detailed/verbose description of the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis. Or subjective documentation is missing.

Discuss Objective data: • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history • Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses

9 (9.00%) – 10 (10.00%)

The video accurately and concisely documents the patient’s physical exam for pertinent systems. Pertinent diagnostic tests and their results are documented, as applicable.

8 (8.00%) – 8 (8.00%)

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are documented, as applicable.

7 (7.00%)

7 (7.00%) – 7 (7.00%)

Documentation of the patient’s physical exam is somewhat vague or contains minor inaccuracies. Diagnostic tests and their results are documented but contain inaccuracies.

Feedback:

What are his symptoms? They should match his diagnosis. Is he using drugs now? If so, you need to speak to it. If you don’t speak to it, it should not be part of his diagnosis. Why do you think he has ADHD? What are his symptoms? How does it interfere with his life? Does he work? These are important things to address. Is he depressed? Anxious? How would you treat that?

0 (0.00%) – 6 (6.00%)

The response provides incomplete, inaccurate, or unnecessarily detailed/verbose documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or objective documentation is missing.

Discuss results of Assessment: • Results of the mental status examination • Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.

18 (18.00%) – 20 (20.00%)

The video accurately documents the results of the mental status exam. Video presents at least three differentials in order of priority for a differential diagnosis of the patient, and a rationale for their selection. Response justifies the primary diagnosis and how it aligns with DSM-5 criteria.

16 (16.00%) – 17 (17.00%)

The video adequately documents the results of the mental status exam. Video presents three differentials for the patient and a rationale for their selection. Response adequately justifies the primary diagnosis and how it aligns with DSM-5 criteria.

14.5 (14.50%)

14 (14.00%) – 15 (15.00%)

The video presents the results of the mental status exam, with some vagueness or inaccuracy. Video presents three differentials for the patient and a rationale for their selection. Response somewhat vaguely justifies the primary diagnosis and how it aligns with DSM-5 criteria.

Feedback:

Support your current diagnosis with data you gathered as to his current problem.

0 (0.00%) – 13 (13.00%)

The response provides an incomplete, inaccurate, or unnecessarily detailed/verbose description of the results of the mental status exam and explanation of the differential diagnoses. Or assessment documentation is missing.

Discuss treatment Plan: • A treatment plan for the patient that addresses psychotherapy and rationales including a plan for follow-up parameters and referrals

18 (18.00%) – 20 (20.00%)

The video clearly and concisely outlines an evidence-based treatment plan for the patient that addresses treatment modality, psychotherapy choice with framework principles, and rationale. Discussion includes a clear and concise follow-up plan and parameters. The discussion includes a clear and concise referral plan.

16.5 (16.50%)

16 (16.00%) – 17 (17.00%)

The video clearly outlines an appropriate treatment plan without evidence-based discussion for the patient that addresses treatment modality, psychotherapy choice with framework principles, and rationale. Discussion includes a clear follow-up plan and parameters. The discussion includes a clear referral plan.

14 (14.00%) – 15 (15.00%)

The response somewhat vaguely or inaccurately outlines a treatment plan for the patient and provides a rationale for the treatment approaches recommended. The discussion is somewhat vague or inaccurate regarding the follow-up plan and parameters. The discussion is somewhat vague or inaccurate regarding a referral plan.

0 (0.00%) – 13 (13.00%)

The response does not address the treatment plan or the treatment plan is not appropriate for the assessment and the diagnosis or is missing elements of the treatment plan. There is no discussion for follow-up and parameters. There is no discussion of a referral plan.

Reflections on this case.

5 (5.00%)

5 (5.00%) – 5 (5.00%)

Reflections are thorough, thoughtful, and demonstrate critical thinking. Reflections contain all 3 elements from the assignment directions including a discussion demonstrating critical thinking of the case related to the HealthyPeople 2030 social health determinates. Clearly and concisely relates discussion to the psychiatric and mental health field.

4 (4.00%) – 4 (4.00%)

Reflections demonstrate critical thinking. Reflections demonstrate critical thinking. Reflections contain 2 of the elements from the assignment directions with one being a basic discussion of the case related to the HealthyPeople 2030 social health determinates. Clearly relates discussion to the psychiatric and mental health field.

3.5 (3.50%) – 3.5 (3.50%)

Reflections are somewhat general or do not demonstrate critical thinking. Reflections contain 1 of the required elements from the assignment directions which is the HealthyPeople 2030 social health determinates. Somewhat vaguely or inaccurately relates discussion to the psychiatric and mental health field.

0 (0.00%) – 3 (3.00%)

Reflections are incomplete, inaccurate, or missing. There are no Reflections elements from the assignment directions (no HeathlyPeople 2030 social health determinates, no health promotion, and no education activity). Missing discussion relating to the psychiatric and mental health field or relates discussion to another specialty realm including medical co-morbidity illnesses.

Comprehensive Psychiatric Evaluation documentation

18 (18.00%) – 20 (20.00%)

The response clearly, accurately, and thoroughly follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.

16 (16.00%) – 17 (17.00%)

The response accurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.

14.5 (14.50%)

14 (14.00%) – 15 (15.00%)

The response follows the Comprehensive Psychiatric Evaluation format to document the selected patient case, with some vagueness and inaccuracy.

Feedback:

Several grammatical mistakes. Someone else’s name on the bottom of each page indicates cut and pasting.

0 (0.00%) – 13 (13.00%)

The response incompletely and inaccurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.

Presentation style

5 (5.00%) – 5 (5.00%)

Presentation style is exceptionally clear, professional, and focused.

4 (4.00%)

4 (4.00%) – 4 (4.00%)

Presentation style is clear, professional, and focused.

3.5 (3.50%) – 3.5 (3.50%)

Presentation style is mostly clear, professional, and focused.

0 (0.00%) – 2 (2.00%)

Presentation style is unclear, unprofessional, and/or unfocused.

 

The rubric total value of 73.50 has been overridden with a value of 78.00 out of 100.

Name:PRAC_6645_Week4_Assignment2_Rubric