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Select a patient that you examined during the last 2 weeks

Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation

Comprehensive psychiatric evaluations are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive 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 2 weeks, using the Comprehensive Psychiatric Evaluation 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 assessment and diagnosis. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
  • 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.
  • 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, and each page must be initialed by your Preceptor. When you submit your document, you should include the complete Comprehensive Psychiatric Evaluation as a Word document, as well as a PDF/images of each page that is initialed and signed by your Preceptor. You must submit your document 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 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. In your presentation:

  • Dress professionally with a lab coat 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?

Rubric Detail

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

Name: PRAC_6635_Week7_Assignment2_Rubric

  Excellent Good Fair Poor
Photo ID display and professional attire 5 (5%) – 5 (5%)

Photo ID is displayed. The student is dressed professionally.

0 (0%) – 0 (0%) 0 (0%) – 0 (0%) 0 (0%) – 0 (0%)

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

Time 5 (5%) – 5 (5%)

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

0 (0%) – 0 (0%) 0 (0%) – 0 (0%) 0 (0%) – 0 (0%)

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

Description of chief complaint and history of present illness 5 (5%) – 5 (5%)

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

4 (4%) – 4 (4%)

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

0 (0%) – 0 (0%) 0 (0%) – 3 (3%)

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

Description of past psychiatric, substance use, medical, social, and family history 5 (5%) – 5 (5%)

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

4 (4%) – 4 (4%)

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

0 (0%) – 0 (0%) 0 (0%) – 3 (3%)

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

Discussion of most recent mental status exam and observations made during interview and review of systems 14 (14%) – 15 (15%)

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.

12 (12%) – 13 (13%)

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

11 (11%) – 11 (11%)

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.

0 (0%) – 10 (10%)

All or most of the discussion is inaccurate or missing.

Discussion of diagnostics with results 9 (9%) – 10 (10%)

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

8 (8%) – 8 (8%)

The student provides an accurate discussion of diagnostics with results.

7 (7%) – 7 (7%)

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

0 (0%) – 6 (6%)

All or most of the discussion is inaccurate or missing.

Diagnosis with three (3) differentials 23 (23%) – 25 (25%)

The student provides an accurate, clear, and complete diagnosis with three (3) differentials.

20 (20%) – 22 (22%)

The student provides an accurate diagnosis with three (3) differentials.

18 (18%) – 19 (19%)

The student provides a vague, inaccurate, less than 3 or incomplete diagnosis with differentials.

0 (0%) – 17 (17%)

All or most of the discussion is inaccurate or missing. Less than 2 diagnosis.

Comprehensive Psychiatric Evaluation documentation 23 (23%) – 25 (25%)

The response clearly, accurately, and thoroughly follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.

20 (20%) – 22 (22%)

The response accurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.

18 (18%) – 19 (19%)

The response follows the Comprehensive Psychiatric Evaluation format to document the selected patient case, with some vagueness and inaccuracy.

0 (0%) – 17 (17%)

The response incompletely and inaccurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.

Presentation style 5 (5%) – 5 (5%)

Presentation style is exceptionally clear, professional, and focused.

4 (4%) – 4 (4%)

Presentation style is clear, professional, and focused.

3 (3%) – 3 (3%)

Presentation style is mostly clear, professional, and focused

0 (0%) – 2 (2%)

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

Total Points: 100

Name: PRAC_6635_Week7_Assignment2_Rubric

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