PPT psuchiatric Managemnt I
Description
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Step 1: For this assignment, students will create a video presentation performing a comprehensive psychiatric evaluation of an infant or toddler. You are expected to choose a child and an adult to conduct an interview with. The child and parent are not required to be actual clinic patients, but merely someone who has agreed to perform the interview with you. You will be graded on your interview skills when interviewing the persons performing as an infant or toddler and a parent. You are expected to ask the patient and the parent questions the same way you do with your patients in the clinic. Both should be available virtually or in-person to answer questions. You may use a Zoom/video call to assess the simulated patient if you do not have a child/parent you can assess face to face.
I expect that you will conduct a mental status exam during the interview. If you don’t ask it or explain how you observed it, then don’t document it. Only the information asked in the video will be used for grading.
Use the rubric as a guide for collecting data. Don’t miss points because something was not addressed.
Use Canvas Studio’s Screen Capture feature to record (voice and video) your presentation. No other medium will be accepted. Upload the comprehensive psychiatric examination document. Your documentation will be graded on what you asked during the session. The instructions for creating the video are listed below:
How do I record a Canvas Studio video with a webcam in a course?Links to an external site.
Step 2: Each student will create a focused SOAP note or PowerPoint presentation. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive psychiatric SOAP note or PowerPoint is to be written using the attached template below. Do not provide a voiceover or video for the PowerPoint. Only the information asked in the video will be used for grading.
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S = |
Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS). Click hereLinks to an external site. for more details |
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O = |
Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; and Mental Status Exam |
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A = |
Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes |
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P = |
Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up |
Other: Incorporate current clinical guidelines NIH Clinical GuidelinesLinks to an external site. or APA Clinical GuidelinesLinks to an external site., research articles, and the role of the PMHNP in your presentation.
- Psychiatric Assessment of Infants and ToddlersLinks to an external site.
- Psychiatric Assessment of Children and AdolescentsLinks to an external site.
Reminder: It is important that you complete this assessment using your critical thinking skills. You are expected to synthesize your clinical assessment, formulate a psychiatric diagnosis, and develop a treatment plan independently. It is not acceptable to document “my preceptor made this diagnosis.” An example of the appropriate descriptors of the clinical evaluation is listed below. It is not acceptable to document “within normal limits.”
Submission Instructions:
In addition to the video demonstrating proficiency in completing a comprehensive psychiatric evaluation, students must upload a comprehensive written submission.
- The written submission should be limited to PowerPoint 10-12 slides or a comprehensive psychiatric note and include all sections of the SOAP note listed above.
- The comprehensive psychiatric examination is original work and logically organized, formatted, and cited in the current APA style, including citation of references. Incorporate a minimum of four current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work. Journal articles and books should be referenced according to APA style, 7th Edition (the library has a copy of the APA Manual).
- Students must wear their lab coats, display their STU or other identification, and conduct the video in a professional setting, or the presentation will not be graded.
- Complete and submit the assignment by 11:59 PM ET Sunday
Grading Rubric
Your assignment will be graded according to the grading rubric.
| Video Case Presentation and Psychiatric SOAP Note Rubric 2022 | ||
|---|---|---|
| Criterios | Calificaciones | Pts |
| Chief Complaint |
4 a >3 pts Exemplary Includes a direct quote from patient about presenting problem 3 a >2 pts Distinguished Includes a direct quote from patient and other unrelated information 2 a >0 pts Developing Includes information but information is NOT a direct quote 0 ptos. Novice Information is completely missing |
/ 4 pts |
|
Demographics – S |
2 ptos. Exemplary Begins with patient initials, age, race, ethnicity, and gender (5 demographics) 1.5 ptos. Distinguished Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity, and gender) 1 ptos. Developing Begins with 3 or less patient demographics (patient initials, age, race, ethnicity, and gender) 0 ptos. Novice Information is completely missing |
/ 2 pts |
|
History of the Present Illness (HPI) – S |
5 a >3 pts Exemplary Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity) 3 a >2 pts Distinguished Includes the presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing 2 a >1 pts Developing Includes the presenting problem and 4 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing 1 a >0 pts Novice The presenting problem is not clearly stated and/or there are < 4 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing |
/ 5 pts |
|
Allergies – S |
2 ptos. Exemplary Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy) 1.5 ptos. Distinguished If allergies are present, students list type Drug, environmental factor, herbal, food, latex name and include severity of allergy OR description of the allergy 1 ptos. Developing If allergies are present, students lists only the type of allergy name 0 ptos. Novice Information is completely missing |
/ 2 pts |
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Review of Systems (ROS) – S |
5 a >3 pts Exemplary Includes a minimum of 3 assessments for each body system, assesses at least 9 body systems directed to chief complaint, AND uses the words “admits” and “denies” 3 a >2 pts Distinguished Includes 3 or fewer assessments for each body system, assesses 5-8 body systems directed to chief complaint, AND uses the words “admits” and “denies” 2 a >0 pts Developing Includes 3 or fewer assessments for each body system, and assesses less than 5 body systems directed to chief complaint, OR student does not use the words “admits” and “denies” 0 ptos. Novice Information is completely missing |
/ 5 pts |
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Vital Signs – O |
2 ptos. Exemplary Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.) 1.5 ptos. Distinguished Includes at least 6 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.) 1 ptos. Developing Includes at least 4 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.) 0 ptos. Novice Information is completely missing |
/ 2 pts |
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Labs, Diagnostic Tests and Screening Tools – O |
3 ptos. Exemplary During the visit: Includes a list of the labs, diagnostic tests or screening tools reviewed at the visit, values of lab results or screening tools, and highlights abnormal values, OR acknowledges no labs/diagnostic tests were reviewed. 2 ptos. Distinguished During the visit: Includes a list of the labs, diagnostic tests, or screening tools reviewed at the visit, but does not include the values of lab results or screening tools, but does not highlight abnormal values. 1 ptos. Developing During the visit: Includes a list of the labs, diagnostic tests, or screening tools reviewed at the visit but does not include the values of the results or highlight abnormal values. 0 ptos. Novice Information is completely missing. |
/ 3 pts |
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Medications-S |
4 a >3 pts Exemplary Includes a list of all of the patient reported psychiatric and medical medications and the diagnosis for the medication (including name, dose, route, frequency) 3 a >2 pts Distinguished Includes a list of all of the patient reported psychiatric and but omits the medical medications and the diagnosis for the medication (including name, dose, route, frequency) 2 a >0 pts Developing Includes a list of some of the patient reported psychiatric and/or medical medications and the diagnosis for the medication (omits the dose, route, frequency of the medications) 0 ptos. Novice Information is completely missing |
/ 4 pts |
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Past Medical History-S |
3 ptos. Exemplary Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current 2 ptos. Distinguished Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current 1 ptos. Developing Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current 0 ptos. Novice Information is completely missing |
/ 3 pts |
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Past Psychiatric History-S |
5 a >3 pts Exemplary Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), year of diagnosis and 3 a >2 pts Distinguished Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (omits addiction treatment), year of diagnosis 2 a >0 pts Developing Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), does not include the year of diagnosis 0 ptos. Novice The information is completely missing |
/ 5 pts |
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Family Psychiatric History-S |
3 ptos. Exemplary Includes an assessment of at least 6 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder and history of suicidal attempts 2 ptos. Distinguished Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder and history of suicidal attempts 1 ptos. Developing Includes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder and history of suicidal attempts 0 ptos. Novice Information is completely missing |
/ 3 pts |
|
Social History-S |
3 ptos. Exemplary Distinguished Includes all 11 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation. 2 ptos. Distinguished Includes at least 8 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation. 1 ptos. Developing Includes all 6 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation. 0 ptos. Novice Information is completely missing. |
/ 3 pts |
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Mental Status Exam-O |
15 a >8 pts Exemplary Includes all 10 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with detailed descriptions for each area 8 a >5 pts Distinguished Includes all 8 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with detailed descriptions for each area 5 a >3 pts Developing Includes >6 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with some descriptions for each area 3 a >0 pts Novice Includes <3 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) OR detailed descriptions is not included for each area |
/ 15 pts |
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Primary Diagnoses-A |
5 a >3 pts Exemplary Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority) 3 a >2 pts Distinguished Includes a clear outline of the accurate diagnoses addressed at the visit but does not list the diagnoses in descending order of priority 2 a >0 pts Developing Includes an inaccurate diagnosis as the principal diagnosis 0 ptos. Novice Information is completely missing |
/ 5 pts |
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Differential Diagnoses-A |
3 ptos. Exemplary Includes at least 2 differential diagnoses that can be supported by the subjective and objective data provided. 2 ptos. Distinguished Includes 1 differential diagnosis that can be supported by the subjective and objective data provided. 1 ptos. Developing Includes at least 1 differential diagnosis that is NOT supported by the subjective and objective data 0 ptos. Novice Information is completely missing |
/ 3 pts |
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Outcome Labs/Screening Tools – O |
3 ptos. Exemplary After the visit: orders appropriate diagnostic/lab testing or screening tool 100% of the time OR acknowledges “no diagnostic testing or screening tool clinically required at this time” 2 ptos. Distinguished After the visit: orders appropriate diagnostic/lab testing 50% of the time OR acknowledges “no diagnostic testing or screening tool clinically required at this time” Our website has a team of professional writers who can help you write any of your homework. They will write your papers from scratch. We also have a team of editors just to make sure all papers are of HIGH QUALITY & PLAGIARISM FREE. To make an Order you only need to click Order Now and we will direct you to our Order Page at Litessays. Then fill Our Order Form with all your assignment instructions. Select your deadline and pay for your paper. You will get it few hours before your set deadline.Fill in all the assignment paper details that are required in the order form with the standard information being the page count, deadline, academic level and type of paper. It is advisable to have this information at hand so that you can quickly fill in the necessary information needed in the form for the essay writer to be immediately assigned to your writing project. Make payment for the custom essay order to enable us to assign a suitable writer to your order. Payments are made through Paypal on a secured billing page. Finally, sit back and relax. |