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Psychiatric notes are a way to reflect on your practicum experiences and connect

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 disorderduring 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 by your Preceptor. When you submit your note, you should include the complete comprehensive evaluation note as a Word document and pdf/images of the completed assignment signed by your Preceptor. You must submit your note using Turnitin.
    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.

    PRAC_6645_Week7_Assignment2_PT1_Rubric

    PRAC_6645_Week7_Assignment2_PT1_Rubric
    Criteria Ratings Pts
    This criterion is linked to a Learning OutcomePhoto ID display and professional attire
    5 to >0.0 ptsExcellentPhoto ID is displayed. The student is dressed professionally. 0 ptsFair 0 ptsGood 0 ptsPoorPhoto 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 ptsExcellentThe video does not exceed the 8-minute time limit. 3 to >0.0 ptsGoodThe video exceeds the 8-minute time limit. (Note: Information presented after 8 minutes will not be evaluated for grade inclusion.) 0 ptsFair 0 ptsPoor
    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 ptsExcellentThe 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 ptsGoodThe 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 ptsFairThe 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 ptsPoorThe 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 ptsExcellentThe 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 ptsGoodThe response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are documented, as applicable. 7 to >6.0 ptsFairDocumentation 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 ptsPoorThe 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 ptsExcellentThe 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 ptsGoodThe 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 ptsFairThe 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 ptsPoorThe 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 ptsExcellentThe 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 ptsGoodThe 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 ptsFairThe 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 ptsPoorThe 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 OutcomePresentation style
    5 to >4.0 ptsExcellentPresentation style is exceptionally clear, professional, and focused. 4 to >3.5 ptsGoodPresentation style is clear, professional, and focused. 3.5 to >2.0 ptsFairPresentation style is mostly clear, professional, and focused. 2 to >0 ptsPoorPresentation style is unclear, unprofessional, and/or unfocused.
    5 pts
    Total Points: 75

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