PRAC 6635 WEEK 7 ASSIGNMENT 2: COMPREHENSIVE PSYCHIATRIC EVALUATION AND PATIENT CASE, DOCUMENTATION PART 1

PRAC 6635 WEEK 7 ASSIGNMENT 2: COMPREHENSIVE PSYCHIATRIC EVALUATION AND PATIENT CASE, DOCUMENTATION PART 1

PRAC 6635 WEEK 7 ASSIGNMENT 2: COMPREHENSIVE PSYCHIATRIC EVALUATION AND PATIENT CASE, DOCUMENTATION PART 1

TO PREPARE

Review this week’s Learning Resources and consider the insights they provide about assessment and diagnosis. Also review the Kaltura Media resource in the Classroom Support Center (accessed via the Help button).

Select a patient that you examined during the last 2 weeks who presented with a disorder other than the one present in your selected case for Week 5.

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Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided in the Learning Resources. There is also a completed exemplar document in the Learning Resources so that you can see an example of the types of information a completed evaluation document should contain. All psychiatric evaluations must be signed by your Preceptor. When you submit your document, you should include the complete Comprehensive Psychiatric Evaluation as a Word document and the completed assignment signed by your Preceptor. You must submit your document using Turn It In.

Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.

Develop a video case presentation, based on your evaluation of this patient, that includes chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis, including differentials that were ruled out.

Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.

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

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 case. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis including differentials that were ruled out.

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. Address the following:

Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?

Objective: What observations did you make during the interview and review of systems?

Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis and why?

Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the Healthy People 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_6635_Week7_Assignment2_Part1__Rubric

PRAC_6635_Week7_Assignment2_Part1__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 >0.0 pts

Excellent

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

0 pts

Fair

0 pts

Good

0 pts

Poor

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

This criterion is linked to a Learning OutcomeDescription of chief complaint and history of present illness
5 to >4.0 pts

Excellent

The student provides an accurate, clear, and complete description of the chief complaint and history of present illness.

4 to >3.0 pts

Good

The student provides an accurate description of the chief complaint and history of present illness.

3 to >1.0 pts

Fair

The student provides a vague, inaccurate, or incomplete description of the chief complaint and history of present illness, or description is missing.

1 to >0 pts

Poor

The student provides a completely inaccurate, or incomplete description of the chief complaint and history of present illness, or the description is missing.

5 pts

This criterion is linked to a Learning OutcomeDescription of past psychiatric, substance use, medical, social, and family history

5 to >4.0 pts

Excellent

The student provides an accurate, clear, and complete description of past psychiatric, substance use, medical, social, and family history.

4 to >3.0 pts

Good

The student provides an accurate description of past psychiatric, substance use, medical, social, and family history.

3 to >1.0 pts

Fair

The student provides a vague, inaccurate, or incomplete description of psychiatric, substance use, medical, social, and family history, or description is missing.

1 to >0 pts

Poor

The student provides a completely inaccurate, or incomplete description of psychiatric, substance use, medical, social, and family history, or description is missing.
5 pts

This criterion is linked to a Learning OutcomeDiscussion of most recent mental status exam and observations made during interview and review of systems
15 to >13.0 pts

Excellent

The student provides an accurate, clear, and complete discussion of results from most recent mental status exam and observations made during interview and review of systems.

13 to >11.0 pts

Good

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The student provides an accurate discussion of results from most recent mental status exam and observations made during interview and review of systems.

11 to >10.0 pts

Fair

The student provides a vague, inaccurate, or incomplete discussion of results from most recent mental status exam and observations made during interview and review of systems.

10 to >0 pts

Poor

All or most of the discussion is inaccurate or missing.
15 pts

This criterion is linked to a Learning OutcomeDiscussion of diagnostics with results
10 to >8.0 pts

Excellent

The student provides an accurate, clear, and complete discussion of diagnostics with results.

8 to >7.0 pts

Good

The student provides an accurate discussion of diagnostics with results.

7 to >6.0 pts

Fair

The student provides a vague, inaccurate, or incomplete discussion of diagnostics with results.

6 to >0 pts

Poor

All or most of the discussion is inaccurate or missing.

10 pts

This criterion is linked to a Learning OutcomeDiagnostic Impression with three (3) differential diagnosesReflection on this case
25 to >22.0 pts

Excellent

The student provides an accurate, clear, and complete diagnostic impression with three (3) differentials. … Reflections are thorough, thoughtful, and demonstrate critical thinking. …Reflections contain all 3 elements from the assignment directions.

22 to >19.0 pts

Good

The student provides an accurate diagnostic impression with three (3) differentials…. Reflections demonstrate critical thinking…. Reflections contain 2 of the elements from the assignment directions.

19 to >17.0 pts

Fair

The student provides a vague, inaccurate, less than 3, or incomplete diagnostic impression with differentials…. Reflections are somewhat general or do not demonstrate critical thinking…. Reflections contain 1 of the required elements from the assignment directions.

17 to >0 pts

Poor

All or most of the discussion is inaccurate or missing. No diagnostic impression and less than 2 differential diagnoses…. Reflections are incomplete, inaccurate, or missing. … There are no Reflections elements from the assignment directions.
25 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 >3.0 pts

Good

Presentation style is clear, professional, and focused.

3 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 pts

Total Points: 75

PRAC_6635_Week7_Assignment2_Part2_Rubric

PRAC_6635_Week7_Assignment2_Part2_Rubric

Criteria Ratings Pts

This criterion is linked to a Learning OutcomeComprehensive Psychiatric Evaluation documentation

25 to >22.0 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).

22 to >19.0 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.

19 to >17.0 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 missing from the uploaded completed assignment.

17 to >0 pts

Poor

The response incompletely and inaccurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case. No preceptor signature.

25 pts

Total Points: 25

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