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Assignment 2: Focused SOAP Note and Patient Case Presentation

INSRUCTION

For this Assignment, you will document information about a patient that you examined during the last 3 weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient. Be sure to incorporate any feedback you received on your Week 3 and Week 7 case presentations into this final presentation for the course. 

To Prepare

· Review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.

· Select a child or adolescent patient that you examined during the last 3 weeks who presented with a disorder for which you have not already created a Focused SOAP Note in Weeks 3 or 7. (For instance, if you selected a patient with anorexia nervosa in Week 7, you must choose a patient with another type of disorder for this week.)

· Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.
Please Note:

· All SOAP notes must be signed, and each page must be initialed by your Preceptor. Note: Electronic signatures are not accepted.

· When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor.

· You must submit your SOAP note using SafeAssign. Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.

· Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record.

· Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.

· Ensure that you have the appropriate lighting and equipment to record the presentation.

The Assignment

Record yourself presenting the complex case study for your clinical patient. 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. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.

· Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.

· Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide:

· 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 (include one health promotion activity and patient education)? 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. 

· Reflection notes: What would you do differently with this patient if you could conduct the session over? 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.

Assignment 2: Focused SOAP Note and Patient Case Presentation

Patient is 44-year-old African American female seen in the clinic with consent for chief complaint of “PTSD” or depression. She reports her little brother died in 2019 and her mother died in 2020. She says she briefly sought a mental health therapist in the past but was unable to connect with the therapists. She reports her family of mental illness is not confirmed but she believes her mother had depression and OCD. She was raised primarily by her mother. She reports a good relationship with her biological father who has been very active in her life. She says her 30-year-old-daughter has ADHD. She reports she was sexually abused by her stepfather from the ages of 6-12 years old and her mother physically abused her. She became pregnant at 14 and was able to earn her GED. Patient reported very poor appetite. She is sleeping only four hours per night and sometimes not at all. She reports she cannot think or focus on her job and is fearful of losing her job. She reports I feel so bad “I don’t even want to put clothes on”. She says she is not actively suicidal but she “Thinks about how it would be if I weren’t here. I don’t have a plan or anything”. She smokes marijuana “All the time” and is increasing her alcohol intake. Provider prescribed escitalopram 5mg every morning for her depression and will increase when appropriate. Hydroxyzine 25 mg three times a day as needed for her anxiety. Patient was educated on abstaining from smoking marijuana and consuming alcohol. Instruct patient in the use and side effects of escitalopram and hydroxyzine. Patient to call 911 for thoughts of suicide and homicide ideation.

PHQ score 21/27.

Diagnosis of Severe Depression

Vital Sign: T-98.6, R-20, P-82, B/P-130/78, Oxygen sat 100% R/A, Wt-170lbs

Plan: in 90 days patient will have decreased symptoms of depression.

Provider educated patient to abstain from smoking marijuana and consumption of alcohol while taking Escitalopram and hydroxyzine as they will affect effectiveness of the medications. Patient verbalized understanding.

Provider educated patient in the use and side effects of escitalopram and hydroxyzine. Instructed patient that feelings of abdominal pain, nausea and heavy headedness will pass and to continue taking medication

Provider will instruct patient to call 911 for thoughts of suicide and homicide ideation.

Follow-up visit in 2 weeks.

Assignment 2: Focused SOAP Note and Patient Case Presentation

Rubric Detail

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

Content

Name: PRAC_6665_Week9_Assignment2_Rubric

  Excellent Good Fair Poor
Photo ID display and professional attire

Points:

Points Range:
5 (5%) – 5 (5%)

Photo ID is displayed. The student is dressed professionally.

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

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

Feedback:

Time

Points:

Points Range:
5 (5%) – 5 (5%)

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

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

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

Feedback:

Discuss Subjective data:

• Chief complaint

• History of present illness (HPI)

• Medications

• Psychotherapy or previous
psychiatric diagnosis

• Pertinent histories and/or ROS

Points:

Points Range:
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.

Feedback:

Points:

Points Range:
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.

Feedback:

Points:

Points Range:
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.

Feedback:

Points:

Points Range:
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.

Feedback:

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

Points:

Points Range:
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.

Feedback:

Points:

Points Range:
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.

Feedback:

Points:

Points Range:
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.

Feedback:

Points:

Points Range:
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.

Feedback:

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.

Points:

Points Range:
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.

Feedback:

Points:

Points Range:
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.

Feedback:

Points:

Points Range:
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.

Feedback:

Points:

Points Range:
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.

Feedback:

Discuss treatment Plan:

• A treatment plan for the patient that addresses psychotherapy; one health promotion activity and one patient education strategy; plan for treatment and management, including alternative therapies; pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters; and a rationale for the approaches selected.

Points:

Points Range:
18 (18%) – 20 (20%)

The video clearly and concisely outlines an evidence-based treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear and concise rationale for the treatment approaches recommended is provided.

Feedback:

Points:

Points Range:
16 (16%) – 17 (17%)

The video clearly outlines an appropriate treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear rationale for the treatment approaches recommended is provided.

Feedback:

Points:

Points Range:
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.

Feedback:

Points:

Points Range:
0 (0%) – 13 (13%)

The response does not address the diagnosis or is missing elements of the treatment plan.

Feedback:

Reflect on this case. Discuss what you learned and what you might do differently.

Points:

Points Range:
5 (5%) – 5 (5%)

Reflections are thorough, thoughtful, and demonstrate critical thinking.

Feedback:

Points:

Points Range:
4 (4%) – 4 (4%)

Reflections demonstrate critical thinking.

Feedback:

Points:

Points Range:
3.5 (3.5%) – 3.5 (3.5%)

Reflections are somewhat general or do not demonstrate critical thinking.

Feedback:

Points:

Points Range:
0 (0%) – 3 (3%)

Reflections are incomplete, inaccurate, or missing.

Feedback:

Focused SOAP Note documentation

Points:

Points Range:
18 (18%) – 20 (20%)

The response clearly, accurately, and thoroughly follows the Focused SOAP Note format to document the selected patient case.

Feedback:

Points:

Points Range:
16 (16%) – 17 (17%)

The response accurately follows the Focused SOAP Note format to document the selected patient case.

Feedback:

Points:

Points Range:
14 (14%) – 15 (15%)

The response follows the Focused SOAP Note format to document the selected patient case, with some vagueness and inaccuracy.

Feedback:

Points:

Points Range:
0 (0%) – 13 (13%)

The response incompletely and inaccurately follows the Focused SOAP Note format to document the selected patient case.

Feedback:

Presentation style

Points:

Points Range:
5 (5%) – 5 (5%)

Presentation style is exceptionally clear, professional, and focused.

Feedback:

Points:

Points Range:
4 (4%) – 4 (4%)

Presentation style is clear, professional, and focused.

Feedback:

Points:

Points Range:
3.5 (3.5%) – 3.5 (3.5%)

Presentation style is mostly clear, professional, and focused

Feedback:

Points:

Points Range:
0 (0%) – 3 (3%)

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

Feedback:

Show Descriptions

Show Feedback

Photo ID display and professional attire–

Levels of Achievement:

Excellent
5 (5%) – 5 (5%)

Photo ID is displayed. The student is dressed professionally.

Good
0 (0%) – 0 (0%)

 

Fair
0 (0%) – 0 (0%)

 

Poor
0 (0%) – 0 (0%)

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

Feedback:

Time–

Levels of Achievement:

Excellent
5 (5%) – 5 (5%)

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

Good
0 (0%) – 0 (0%)

 

Fair
0 (0%) – 0 (0%)

 

Poor
0 (0%) – 0 (0%)

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

Feedback:

Discuss Subjective data:

• Chief complaint

• History of present illness (HPI)

• Medications

• Psychotherapy or previous
psychiatric diagnosis

• Pertinent histories and/or ROS

Levels of Achievement:

Excellent
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.

Good
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.

Fair
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.

Poor
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.

Feedback:

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–

Levels of Achievement:

Excellent
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.

Good
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.

Fair
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.

Poor
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.

Feedback:

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.–

Levels of Achievement:

Excellent
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.

Good
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.

Fair
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.

Poor
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.

Feedback:

Discuss treatment Plan:

• A treatment plan for the patient that addresses psychotherapy; one health promotion activity and one patient education strategy; plan for treatment and management, including alternative therapies; pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters; and a rationale for the approaches selected.–

Levels of Achievement:

Excellent
18 (18%) – 20 (20%)

The video clearly and concisely outlines an evidence-based treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear and concise rationale for the treatment approaches recommended is provided.

Good
16 (16%) – 17 (17%)

The video clearly outlines an appropriate treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear rationale for the treatment approaches recommended is provided.

Fair
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.

Poor
0 (0%) – 13 (13%)

The response does not address the diagnosis or is missing elements of the treatment plan.

Feedback:

Reflect on this case. Discuss what you learned and what you might do differently.–

Levels of Achievement:

Excellent
5 (5%) – 5 (5%)

Reflections are thorough, thoughtful, and demonstrate critical thinking.

Good
4 (4%) – 4 (4%)

Reflections demonstrate critical thinking.

Fair
3.5 (3.5%) – 3.5 (3.5%)

Reflections are somewhat general or do not demonstrate critical thinking.

Poor
0 (0%) – 3 (3%)

Reflections are incomplete, inaccurate, or missing.

Feedback:

Focused SOAP Note documentation–

Levels of Achievement:

Excellent
18 (18%) – 20 (20%)

The response clearly, accurately, and thoroughly follows the Focused SOAP Note format to document the selected patient case.

Good
16 (16%) – 17 (17%)

The response accurately follows the Focused SOAP Note format to document the selected patient case.

Fair
14 (14%) – 15 (15%)

The response follows the Focused SOAP Note format to document the selected patient case, with some vagueness and inaccuracy.

Poor
0 (0%) – 13 (13%)

The response incompletely and inaccurately follows the Focused SOAP Note format to document the selected patient case.

Feedback:

Presentation style–

Levels of Achievement:

Excellent
5 (5%) – 5 (5%)

Presentation style is exceptionally clear, professional, and focused.

Good
4 (4%) – 4 (4%)

Presentation style is clear, professional, and focused.

Fair
3.5 (3.5%) – 3.5 (3.5%)

Presentation style is mostly clear, professional, and focused

Poor
0 (0%) – 3 (3%)

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

Feedback:

Total Points: 100

Name: PRAC_6665_Week9_Assignment2_Rubric

Assignment 2: Focused SOAP Note and Patient Case Presentation

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Week (enter week #): (Enter assignment title)

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6665: PMHNP Care Across the Lifespan I

Faculty Name

Assignment Due Date

Subjective:

CC (chief complaint):

HPI:

Substance Current Use:

Medical History:

· Current Medications:

· Allergies:

· Reproductive Hx:

ROS:

· GENERAL:

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:

Diagnostic Impression:

Reflections:

Case Formulation and Treatment Plan: 

References

© 2021 Walden University

Page 1 of 3

Assignment 2: Focused SOAP Note And Patient Case Presentation

 

For this Assignment, you will document information about a patient that you examined during the last 3 weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient. Be sure to incorporate any feedback you received on your Week 3 and Week 7 case presentations into this final presentation for the course. 

To Prepare

 Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide:

  • 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 (include one health promotion activity and patient education)? 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. 
  • Reflection notes: What would you do differently with this patient if you could conduct the session over? 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.

Assignment 2: Focused SOAP Note and Patient Case Presentation

NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar

INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY

If you are struggling with the format or remembering what to include, follow the Focused SOAP Note 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. 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: Discuss 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 FOCUSED SOAP psychiatric evaluation is typically the follow-up visit patient note. You will practice writing this type of note in this course. You will be focusing more on the symptoms from your differential diagnosis from the comprehensive psychiatric evaluation narrowing to your diagnostic impression. You will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)

EXEMPLAR BEGINS HERE

Subjective:

CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why 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 presents for medication management follow up for anxiety. He was initiated sertraline last appt which he finds was effective for two weeks then symptoms began to return.

Or

P.H., a 16-year-old Hispanic female, presents for follow up to discuss previous psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications as we deferred until further testing and screening was conducted.

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. First what is bringing the patient to your follow up evaluation? Document symptom onset, duration, frequency, severity, and impact. What has worsened or improved since last appointment? What stressors are they facing? Your description here will guide your differential diagnoses into your diagnostic impression. 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.

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.

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

ROS: Cover all body systems that may help you include or rule out a differential diagnosis. Please note: THIS IS DIFFERENT from a physical examination!

You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Objective:

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, pseudohallucinations, 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-year-old 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. 


Diagnostic Impression: You must begin to narrow your differential diagnosis to your diagnostic impression. You must explain how and why (your rationale) you ruled out any of your differential diagnoses. You must explain how and why (your rationale) you concluded to your diagnostic impression. You will use supporting evidence from the literature to support your rationale. 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 assessment and diagnostic impression 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 (demonstrating 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 including psychotherapy and/or psychopharmacology, 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. If you are completing this for a practicum, what does your preceptor document?

Risks and benefits of medications are discussed including non- treatment. Potential side effects of medications discussed (be detailed in what side effects discussed). Informed client not to stop medication abruptly without discussing with providers. Instructed to call and report any adverse reactions. Discussed risk of medication with pregnancy/fetus, encouraged birth control, discussed if does become pregnant to inform provider as soon as possible. Discussed how some medications might decreased birth control pill, would need back up method (exclude for males).

Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. Discussed how drugs/alcohol affect mental health, physical health, sleep architecture.

Initiation of (list out any medication and why prescribed, any therapy services or referrals to specialist):

Client was encouraged to continue with case management and/or therapy services (if not provided by you)

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 PMP report (only if actually completed)

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:

Labs ordered and/or reviewed (write out what diagnostic test ordered, rationale for ordering, and if discussed fasting/non fasting or other patient education)

Return to clinic:

Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care.



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.

© 2021 Walden University Page 1 of 3

Assignment 2: Focused SOAP Note and Patient Case Presentation

Assignment 2: Focused SOAP 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. Focused SOAP 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 during the last 4 weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient. 

To Prepare

Review the Kaltura Media Uploader resource for help creating your self-recorded Kaltura video

· Select an adult patient that you examined during the last 4 weeks who presented with a disorder other than the disorder present in your Week 3 Case Presentation.

· Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.
Please Note:

· All SOAP notes must be signed, and each page must be initialed by your Preceptor.
Note: Electronic signatures are not accepted.

· When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor.

· You must submit your SOAP note using SafeAssign.
Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.

· Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record.

· Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.

· Ensure that you have the appropriate lighting and equipment to record the presentation.

The Assignment

Record yourself presenting the complex case study for your clinical patient. 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. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.

· Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.

· Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide:

· 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 patient 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. 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 over? 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.

Assignment 2: Focused SOAP Note and Patient Case Presentation

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Week (enter week #): (Enter assignment title)

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6665: PMHNP Care Across the Lifespan I

Faculty Name

Assignment Due Date

Subjective:

CC (chief complaint):

HPI:

Substance Current Use:

Medical History:

· Current Medications:

· Allergies:

· Reproductive Hx:

ROS:

· GENERAL:

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:

Diagnostic Impression:

Reflections:

Case Formulation and Treatment Plan: 

References

© 2021 Walden University

Page 1 of 3

Assignment 2: Focused SOAP Note And Patient Case Presentation

 PLEASE FOLLOW INSTRUCTIO BELOW, ZERO PLAGIARISM, FIVE REFERENCES NOT MORE THAN FIVE YEARS, 7TH APA FOMAT & SEE TEMPLATE ATTACHED

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. Focused SOAP 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 during the last 4 weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient. 

 

Select an adult patient that you examined during the last 4 weeks who presented with a disorder other than the disorder present in your Week 3 Case Presentation.

  • Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.
    Please Note:

    • All SOAP notes must be signed, and each page must be initialed by your Preceptor.
      Note: Electronic signatures are not accepted.
    • When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor.
    • You must submit your SOAP note using SafeAssign.
      Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.
  • Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record.
  • Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
  • Ensure that you have the appropriate lighting and equipment to record the presentation.

The Assignment

Record yourself presenting the complex case study for your clinical patient. In your presentatio

Assignment 2: Focused SOAP Note and Patient Case Presentation

CASE STUDY

Subjective

Patient is 24-year-old AA female seen today via Telehealth with consent obtained. She reports that she has been going through stuffs and need specialist to address her mood issues. She continued that this mood issue days’ back to 2019 and she was put on Seroquel. However, she admits that because she was pregnant then, she did not go back to continue to get help. After birth according to her, she navigated through life barely until now. Presently, I have been going through stressful things and am beginning to get aggressive with people. I noticed that am verbally and physically abusive to people for little stuff or triggers.” I need help”. She gave a background history that she experienced traumatic life with stepfather children abuse sexually at age of 10. Growing up with no parents in my life affected me also. I had couple of medical and mental health hospitalization. In one of the admissions in psychiatric hospital, I was given Seroquel and I feel like i need to get back to that as it helps me with my mood and sleep. Currently, I hardly get 4 hours of sleep and sometimes I do not get any.

Assessment
Patient report that her mood issue dates to 2019 and she was put on Seroquel. However, she admits that because she was pregnant then, she did not go back to continue to get help. After birth according to her, she navigated through life barely until now. Presently, I have been going through stressful things and am beginning to get aggressive with people. I noticed that am verbally and physically abusive to people for little stuff or triggers.” I need help”. She gave a background history that she experienced traumatic life with stepfather children abuse sexually at age of 10. Growing up with no parents in my life affected me also. I had couple of medical and mental health hospitalization. In one of the admissions in psychiatric hospital, I was given Seroquel and I feel like i need to get back to that as it helps me with my mood and sleep. Currently, I hardly have up to 4 hours of sleep and sometimes I do not get any. The provider reviewed her chart and condition and believe she will benefit from Therapy and will resume Seroquel 50mg at bedtime. Educated her about her disease’s progression and medication side effects.

PHQ 9 score-18/27

Diagnoses (F31.9) Bipolar disorder, unspecified

Plan

Plan in 90 days is to decrease mood disorder

To call 911 feeling suicidal or homicidal

Take prescribed Seroquel 50mg

Educated her on medication side effects or interactions

Patient is refer to Psychotherapy

To follow up in 4 weeks.

MEDICATIONS

Quetiapine Fumarate (SEROquel) 50 MG 1 tablet by mouth daily at bedtime

Assignment 2: Focused SOAP Note and Patient Case Presentation

Rubric Detail

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

Content

Name: PRAC_6665_Week7_Assignment2_Rubric

  Excellent Good Fair Poor
Photo ID display and professional attire

Points:

Points Range:
5 (5%) – 5 (5%)

Photo ID is displayed. The student is dressed professionally.

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

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

Feedback:

Time

Points:

Points Range:
5 (5%) – 5 (5%)

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

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

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

Feedback:

Discuss Subjective data:

• Chief complaint

• History of present illness (HPI)

• Medications

• Psychotherapy or previous
psychiatric diagnosis

• Pertinent histories and/or ROS

Points:

Points Range:
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.

Feedback:

Points:

Points Range:
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.

Feedback:

Points:

Points Range:
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.

Feedback:

Points:

Points Range:
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.

Feedback:

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

Points:

Points Range:
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.

Feedback:

Points:

Points Range:
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.

Feedback:

Points:

Points Range:
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.

Feedback:

Points:

Points Range:
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.

Feedback:

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.

Points:

Points Range:
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.

Feedback:

Points:

Points Range:
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.

Feedback:

Points:

Points Range:
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.

Feedback:

Points:

Points Range:
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.

Feedback:

Discuss treatment Plan:

• A treatment plan for the patient that addresses psychotherapy; one health promotion activity and one patient education strategy; plan for treatment and management, including alternative therapies; pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters; and a rationale for the approaches selected.

Points:

Points Range:
18 (18%) – 20 (20%)

The video clearly and concisely outlines an evidence-based treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear and concise rationale for the treatment approaches recommended is provided.

Feedback:

Points:

Points Range:
16 (16%) – 17 (17%)

The video clearly outlines an appropriate treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear rationale for the treatment approaches recommended is provided.

Feedback:

Points:

Points Range:
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.

Feedback:

Points:

Points Range:
0 (0%) – 13 (13%)

The response does not address the diagnosis or is missing elements of the treatment plan.

Feedback:

Reflect on this case. Discuss what you learned and what you might do differently.

Points:

Points Range:
5 (5%) – 5 (5%)

Reflections are thorough, thoughtful, and demonstrate critical thinking.

Feedback:

Points:

Points Range:
4 (4%) – 4 (4%)

Reflections demonstrate critical thinking.

Feedback:

Points:

Points Range:
3.5 (3.5%) – 3.5 (3.5%)

Reflections are somewhat general or do not demonstrate critical thinking.

Feedback:

Points:

Points Range:
0 (0%) – 3 (3%)

Reflections are incomplete, inaccurate, or missing.

Feedback:

Focused SOAP Note documentation

Points:

Points Range:
18 (18%) – 20 (20%)

The response clearly, accurately, and thoroughly follows the Focused SOAP Note format to document the selected patient case.

Feedback:

Points:

Points Range:
16 (16%) – 17 (17%)

The response accurately follows the Focused SOAP Note format to document the selected patient case.

Feedback:

Points:

Points Range:
14 (14%) – 15 (15%)

The response follows the Focused SOAP Note format to document the selected patient case, with some vagueness and inaccuracy.

Feedback:

Points:

Points Range:
0 (0%) – 13 (13%)

The response incompletely and inaccurately follows the Focused SOAP Note format to document the selected patient case.

Feedback:

Presentation style

Points:

Points Range:
5 (5%) – 5 (5%)

Presentation style is exceptionally clear, professional, and focused.

Feedback:

Points:

Points Range:
4 (4%) – 4 (4%)

Presentation style is clear, professional, and focused.

Feedback:

Points:

Points Range:
3.5 (3.5%) – 3.5 (3.5%)

Presentation style is mostly clear, professional, and focused

Feedback:

Points:

Points Range:
0 (0%) – 3 (3%)

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

Feedback:

Show Descriptions

Show Feedback

Photo ID display and professional attire–

Levels of Achievement:

Excellent
5 (5%) – 5 (5%)

Photo ID is displayed. The student is dressed professionally.

Good
0 (0%) – 0 (0%)

 

Fair
0 (0%) – 0 (0%)

 

Poor
0 (0%) – 0 (0%)

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

Feedback:

Time–

Levels of Achievement:

Excellent
5 (5%) – 5 (5%)

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

Good
0 (0%) – 0 (0%)

 

Fair
0 (0%) – 0 (0%)

 

Poor
0 (0%) – 0 (0%)

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

Feedback:

Discuss Subjective data:

• Chief complaint

• History of present illness (HPI)

• Medications

• Psychotherapy or previous
psychiatric diagnosis

• Pertinent histories and/or ROS

Levels of Achievement:

Excellent
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.

Good
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.

Fair
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.

Poor
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.

Feedback:

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–

Levels of Achievement:

Excellent
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.

Good
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.

Fair
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.

Poor
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.

Feedback:

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.–

Levels of Achievement:

Excellent
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.

Good
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.

Fair
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.

Poor
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.

Feedback:

Discuss treatment Plan:

• A treatment plan for the patient that addresses psychotherapy; one health promotion activity and one patient education strategy; plan for treatment and management, including alternative therapies; pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters; and a rationale for the approaches selected.–

Levels of Achievement:

Excellent
18 (18%) – 20 (20%)

The video clearly and concisely outlines an evidence-based treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear and concise rationale for the treatment approaches recommended is provided.

Good
16 (16%) – 17 (17%)

The video clearly outlines an appropriate treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear rationale for the treatment approaches recommended is provided.

Fair
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.

Poor
0 (0%) – 13 (13%)

The response does not address the diagnosis or is missing elements of the treatment plan.

Feedback:

Reflect on this case. Discuss what you learned and what you might do differently.–

Levels of Achievement:

Excellent
5 (5%) – 5 (5%)

Reflections are thorough, thoughtful, and demonstrate critical thinking.

Good
4 (4%) – 4 (4%)

Reflections demonstrate critical thinking.

Fair
3.5 (3.5%) – 3.5 (3.5%)

Reflections are somewhat general or do not demonstrate critical thinking.

Poor
0 (0%) – 3 (3%)

Reflections are incomplete, inaccurate, or missing.

Feedback:

Focused SOAP Note documentation–

Levels of Achievement:

Excellent
18 (18%) – 20 (20%)

The response clearly, accurately, and thoroughly follows the Focused SOAP Note format to document the selected patient case.

Good
16 (16%) – 17 (17%)

The response accurately follows the Focused SOAP Note format to document the selected patient case.

Fair
14 (14%) – 15 (15%)

The response follows the Focused SOAP Note format to document the selected patient case, with some vagueness and inaccuracy.

Poor
0 (0%) – 13 (13%)

The response incompletely and inaccurately follows the Focused SOAP Note format to document the selected patient case.

Feedback:

Presentation style–

Levels of Achievement:

Excellent
5 (5%) – 5 (5%)

Presentation style is exceptionally clear, professional, and focused.

Good
4 (4%) – 4 (4%)

Presentation style is clear, professional, and focused.

Fair
3.5 (3.5%) – 3.5 (3.5%)

Presentation style is mostly clear, professional, and focused

Poor
0 (0%) – 3 (3%)

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

Feedback:

Total Points: 100

Name: PRAC_6665_Week7_Assignment2_Rubric