[SOLVED] Comprehensive Psychiatric Evaluation Note

Assignment 2: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation

Photo Credit: Pexels
Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive psychiatric evaluation notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you examined at your practicum site, using the Comprehensive Psychiatric Evaluation Note Template provided. You will then use this note to develop and record a case presentation for this patient.
To Prepare
Review this week’s Learning Resources and consider the insights they provide about impulse-control and conduct disorders.
Select a patient for whom you conducted psychotherapy for an impulse control or conduct disorder during the last 6 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide. All psychiatric evaluation notes must be signed, and each page must be initialed by your Preceptor. When you submit your note, you should include the complete comprehensive evaluation note as a Word document and pdf/images of each page that is initialed and signed by your Preceptor. You must submit your note using SafeAssign.
Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Grading Policy.
Then, based on your evaluation of this patient, develop a video presentation of the case. Plan your presentation using the Assignment rubric and rehearse what you plan to say. Be sure to review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
Include at least five scholarly resources to support your assessment and diagnostic reasoning.
Ensure that you have the appropriate lighting and equipment to record the presentation.
The Assignment
Record yourself presenting the complex case 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. 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 diagnostic criteria and is supported by the patient’s symptoms.
Plan: What was your plan for psychotherapy (including one health promotion activity and one patient education strategy)? What was your plan for treatment and management, including alternative therapies? Include 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 again?
By Day 7
Submit your Video and Comprehensive Psychiatric Evaluation Note Assignment. You must submit two files for the evaluation note, including a Word document and scanned pdf/images of each page that is initialed and signed by your Preceptor.

Photo ID display and professional attire–
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.
Time–
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%) – 3 (3%)
The video exceeds the 8-minute time limit. (Note: Information presented after 8 minutes will not be evaluated for grade inclusion.)
Discuss Subjective data:
• Chief complaint
• History of present illness (HPI)
• Medications
• Psychotherapy or previous psychiatric diagnosis
• Pertinent histories and/or ROS–
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.
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–
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.
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.–
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.
Discuss treatment Plan:
• A treatment plan for the patient that addresses psychotherapy (including one health promotion activity and one patient education strategy); plan for treatment and management, including alternative therapies; nonpharmacologic treatments, alternative therapies, and follow-up parameters; and a rationale for the approaches selected.–
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, 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, 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.
Reflect on this case. Discuss what you learned and what you might do differently.–
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.
Comprehensive Psychiatric Evaluation documentation–
Excellent 18 (18%) – 20 (20%)
The response clearly, accurately, and thoroughly follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.
Good 16 (16%) – 17 (17%)
The response accurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.
Fair 14 (14%) – 15 (15%)
The response follows the Comprehensive Psychiatric Evaluation format to document the selected patient case, with some vagueness and inaccuracy.
Poor 0 (0%) – 13 (13%)
The response incompletely and inaccurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.
Presentation style–
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%) – 2 (2%)
Presentation style is unclear, unprofessional, and/or unfocused.
Total Points: 100
Name: PRAC_6645_Week7_Assignment2_Rubric

 

Classroom Productions. (Producer). (2016). Impulse and conduct disorders [Video]. Walden University.

Professor Hartung. (2020). Multisystemic therapy (MST) for at-risk youth and juveniles informational webinar [Video]. YouTube. https://www.youtube.com/watch?v=yHbTEWCDlpE

Comprehensive Psychiatric Evaluation Note