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- 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 completed assignment document signed by your Preceptor.
SUBMISSION INFORMATION
Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.
- To submit your completed assignment, save your Assignment as WK7Assgn2+last name+first initial.
- Then, click on Start Assignment near the top of the page.
- Next, click on Upload File and select Submit Assignment for review.
Rubric
PRAC_6645_Week7_Assignment2_Rubric
| Criteria | Ratings | Pts |
|---|---|---|
| This criterion is linked to a Learning OutcomePhoto ID display and professional attire |
5 to >0.0 pts Excellent Photo ID is displayed. The student is dressed professionally.
0 pts Fair
0 pts Good
0 pts Poor Photo ID is not displayed. Student must remedy this before grade is posted. The student is not dressed professionally.
|
5 pts |
| This criterion is linked to a Learning OutcomeTime |
5 to >3.0 pts Excellent The video does not exceed the 8-minute time limit.
3 to >0.0 pts Good The video exceeds the 8-minute time limit. (Note: Information presented after 8 minutes will not be evaluated for grade inclusion.)
0 pts Fair
0 pts Poor
|
5 pts |
| This criterion is linked to a Learning OutcomeDiscuss Subjective data:• Chief complaint• History of present illness (HPI)• Medications• Psychotherapy or previous psychiatric diagnosis• Pertinent histories and/or ROS |
10 to >8.0 pts Excellent 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 to >7.0 pts Good 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 to >6.0 pts Fair 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.
6 to >0 pts Poor 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.
|
10 pts |
| This criterion is linked to a Learning OutcomeDiscuss 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 |
10 to >8.0 pts Excellent 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 to >7.0 pts Good The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are documented, as applicable.
7 to >6.0 pts Fair Documentation of the patient’s physical exam is somewhat vague or contains minor inaccuracies. Diagnostic tests and their results are documented but contain inaccuracies.
6 to >0 pts Poor 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.
|
10 pts |
| This criterion is linked to a Learning OutcomeDiscuss 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. |
20 to >17.0 pts Excellent 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.
17 to >15.0 pts Good 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.
15 to >13.0 pts Fair 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.
13 to >0 pts Poor 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.
|
20 pts |
| This criterion is linked to a Learning OutcomeDiscuss treatment Plan:• A treatment plan for the patient that addresses psychotherapy and rationales including a plan for follow-up parameters and referrals |
20 to >17.0 pts Excellent 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.
17 to >15.0 pts Good 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.
15 to >13.0 pts Fair 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.
13 to >0 pts Poor 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.
|
20 pts |
| This criterion is linked to a Learning OutcomeReflections on this case. |
5 to >4.0 pts Excellent 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 to >3.5 pts Good 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 to >3.0 pts Fair 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.
3 to >0 pts Poor 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.
|
5 pts |
| This criterion is linked to a Learning OutcomeComprehensive Psychiatric Evaluation documentation |
20 to >17.0 pts Excellent The response clearly, accurately, and thoroughly follows the Comprehensive Psychiatric Evaluation format to document the selected patient case. Preceptor signature and date pdf/image is uploaded on the completed assignment (not an electronic signature).
17 to >15.0 pts Good The response accurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case. Preceptor signature and date pdf/image is uploaded on the completed assignment but is an electronic signature.
15 to >13.0 pts Fair The response follows the Comprehensive Psychiatric Evaluation format to document the selected patient case, with some vagueness and inaccuracy Preceptor signature and date pdf/image is uploaded on the completed assignment but is an electronic signature.
13 to >0 pts Poor The response incompletely and inaccurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case. No preceptor signature.
|
20 pts |
| This criterion is linked to a Learning OutcomePresentation style |
5 to >4.0 pts Excellent Presentation style is exceptionally clear, professional, and focused.
4 to >3.5 pts Good Presentation style is clear, professional, and focused.
3.5 to >2.0 pts Fair Presentation style is mostly clear, professional, and focused.
2 to >0 pts Poor Presentation style is unclear, unprofessional, and/or unfocused.
|
5 |