COMPREHENSIVE PSYCHIATRIC EVALUATION AND PATIENT CASE PRESENTATION, DOCUMENTATION
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COMPREHENSIVE PSYCHIATRIC EVALUATION AND PATIENT CASE PRESENTATION, DOCUMENTATION
For this Assignment, you will document information about a patient that you examined during the last 3 weeks, using the Comprehensive Psychiatric Evaluation Template provided. You will then use this note to develop and record a case presentation for this patient. Be sure to incorporate any feedback you received on your Week 3 and Week 6 case presentations into this final presentation for the course.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCE
TO PREPARE
Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media resources in the Classroom Support Center (accessed via the Help button).
Select a patient that you examined during the last 3 weeks who presented with a disorder for which you have not already conducted an evaluation in Weeks 3 or 6. (For instance, if you selected a patient with OCD in Week 6, you must choose a patient with another type of disorder for this week.) 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 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.
Then, based on your evaluation of this patient, develop a video case presentation 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 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.
BY DAY 7
Submit your Comprehensive Psychiatric Evaluation documentation, including a Word document and scanned PDF/images of each page that is initialed and signed by your Preceptor.
Note: In Week 9: Assignment 2, Part 1 you will submit the Video Evaluation Presentation.
SUBMISSION INFORMATION
Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.
To submit your completed assignment, save your Assignment as WK9Assgn2_LastName_Firstinitial
Then, click on Start Assignment near the top of the page.
Next, click on Upload File and select Submit Assignment for review.
Rubric
PRAC_6635_Week9_Assignment2_Part2__Rubric
PRAC_6635_Week9_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
LEARNING RESOURCES
Required Readings
Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
Chapter 31, “Assessing Personality Disorders”
Chapter 32, “How to Educate Your Patient”
HSoft Corporation. (2020). Meditrek: HomeLinks to an external site.. https://edu.meditrek.com/Default.html
Note: Use this website to log into Meditrek to report your clinical hours and patient encounters.
Document: Comprehensive Psychiatric Evaluation Template Download Comprehensive Psychiatric Evaluation Template(Word document)
Document: Comprehensive Psychiatric Evaluation Exemplar Download Comprehensive Psychiatric Evaluation Exemplar(Word document)
Recommended
American Psychiatric Association. (2022). Sexual dysfunctionsLinks to an external site.. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.).
American Psychiatric Association. (2022). Personality disordersLinks to an external site.. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.).
American Psychiatric Association. (2022). Paraphilic disordersLinks to an external site.. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.).
Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.
Walden University. (2020). College of Nursing practicum manual: Master of science in nursing (MSN) and post-master’s certificate programsLinks to an external site.. https://academicguides.waldenu.edu/fieldexperience/son/formsanddocuments
Walden University Field Experience. (2020a). Field experience: College of NursingLinks to an external site.. https://academicguides.waldenu.edu/fieldexperience/son/home
Walden University Field Experience. (2020b). Student practicum resources: NP student orientationLinks to an external site.. https://academicguides.waldenu.edu/StudentPracticum/NP_StudentOrientation
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