COMPREHENSIVE PSYCHIATRIC EVALUATION NOTE AND PATIENT CASE PRESENTATION, PART 1
COMPREHENSIVE PSYCHIATRIC EVALUATION NOTE AND PATIENT CASE PRESENTATION, PART 1
Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. 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 in a group setting during the last 4 weeks, using the Comprehensive Psychiatric Evaluation Note Template provided. You will then use this note to develop and record a case presentation for this patient.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
TO PREPARE
Review this week’s Learning Resources and consider the insights they provide about clinical practice guidelines.
Select a group patient for whom you conducted psychotherapy for a mood disorderduring the last 4 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 by your Preceptor. When you submit your note, you should include the complete comprehensive psychiatric evaluation note as a Word document and pdf/images the completed assignment signed by your Preceptor. You must submit your note using Turnitin.
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 Kalturasupport resources in the Classroom Support Center found by clicking on the Help
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 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 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-TR diagnostic criteria and is supported by the patient’s symptoms.
Plan: Describe your treatment modality and your plan for psychotherapy. Explain the principles of psychotherapy that underline your chosen treatment plan to support your rationale for the chosen psychotherapy framework. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this psychotherapy session?
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 Video and Comprehensive Psychiatric Evaluation Note. You must submit two files for the evaluation note, including a Word document and scanned pdf/images the completed assignment signed by your Preceptor.
SUBMISSION INFORMATION – PART 1: RECORDING
To submit your video response entry:
Click on Start Assignment near the top of the page.
Next, click Text Entry and then click the Embed Kaltura Media button.
Select your recorded video under My Media.
Check the box for the End-User License Agreement and select Submit Assignment for review.
SUBMISSION INFORMATION – PART 2: COMPREHENSIVE PSYCHIATRIC EVALUATION NOTE
To submit Part 2 of this Assignment, click on the following link:
Week 4 Assignment 2, Part 2
Rubric
PRAC_6645_Week4_Assignment2_PT1_Rubric
PRAC_6645_Week4_Assignment2_PT1_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 >3.0 pts
Excellent
The video does not exceed the 8-minute time limit.
3 to >0.0 pts
Good
The video exceeds the 8-minute time limit. (Note: Information presented after 8 minutes will not be evaluated for grade inclusion.)
0 pts
Fair
0 pts
Poor
5 pts
This criterion is linked to a Learning OutcomeDiscuss Subjective data:• Chief complaint• History of present illness (HPI)• Medications• Psychotherapy or previous psychiatric diagnosis• Pertinent histories and/or ROS
10 to >8.0 pts
Excellent
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.
8 to >7.0 pts
Good
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.
7 to >6.0 pts
Fair
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.
6 to >0 pts
Poor
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.
10 pts
This criterion is linked to a Learning OutcomeDiscuss 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
10 to >8.0 pts
Excellent
The video accurately and concisely documents the patient’s physical exam for pertinent systems. Pertinent diagnostic tests and their results are documented, as applicable.
8 to >7.0 pts
Good
The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are documented, as applicable.
7 to >6.0 pts
Fair
Documentation of the patient’s physical exam is somewhat vague or contains minor inaccuracies. Diagnostic tests and their results are documented but contain inaccuracies.
6 to >0 pts
Poor
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.
10 pts
This criterion is linked to a Learning OutcomeDiscuss 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.
20 to >17.0 pts
Excellent
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.
17 to >15.0 pts
Good
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.
15 to >13.0 pts
Fair
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.
13 to >0 pts
Poor
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.
20 pts
This criterion is linked to a Learning OutcomeDiscuss treatment Plan:• A treatment plan for the patient that addresses psychotherapy and rationales including a plan for follow-up parameters and referrals
20 to >17.0 pts
Excellent
The video clearly and concisely outlines an evidence-based treatment plan for the patient that addresses treatment modality, psychotherapy choice with framework principles, and rationale. … Discussion includes a clear and concise follow-up plan and parameters…. The discussion includes a clear and concise referral plan.
17 to >15.0 pts
Good
The video clearly outlines an appropriate treatment plan without evidence-based discussion for the patient that addresses treatment modality, psychotherapy choice with framework principles, and rationale. … Discussion includes a clear follow-up plan and parameters…. The discussion includes a clear referral plan.
15 to >13.0 pts
Fair
The response somewhat vaguely or inaccurately outlines a treatment plan for the patient and provides a rationale for the treatment approaches recommended…. The discussion is somewhat vague or inaccurate regarding the follow-up plan and parameters…. The discussion is somewhat vague or inaccurate regarding a referral plan.
13 to >0 pts
Poor
The response does not address the treatment plan or the treatment plan is not appropriate for the assessment and the diagnosis or is missing elements of the treatment plan. … There is no discussion for follow-up and parameters. … There is no discussion of a referral plan.
20 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 >3.5 pts
Good
Presentation style is clear, professional, and focused.
3.5 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
LEARNING RESOURCES
Required Readings
American Group Psychotherapy Association.Links to an external site. (2007–2020). Practice guidelines for group psychotherapy. https://www.agpa.org/home/practice-resources/practice-guidelines-for-group-psychotherapy
American Psychiatric Association.Links to an external site. (2020). Clinical practice guidelines. https://psychiatryonline.org/guidelines
Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
Chapter 23, “Assessing Mood Disorders I: Depressive Disorders”
Chapter 24, “Assessing Mood Disorders II: Bipolar Disorders”
MeditrekLinks 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.
National Institute for Health and Care ExcellenceLinks to an external site.
https://www.nice.org.uk/
U.S. Department of Veterans Affairs. (2020). VA/DoD clinical practice guidelines.Links to an external site. https://www.healthquality.va.gov/
Document: Comprehensive Psychiatric Evaluation Note Template (Word document)Download Comprehensive Psychiatric Evaluation Note Template (Word document)
Document: Comprehensive Psychiatric Evaluation Note Exemplar (Word document)Download Comprehensive Psychiatric Evaluation Note Exemplar (Word document)
Tutorial: Kaltura Media UploaderLinks to an external site.
Required Media
Center for Reality Therapy. (2010). Counseling with a group of not so eager clients [Video].Links to an external site. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/counseling-with-a-group-of-not-so-eager-clients
College of Nurses of Ontario CNO. (2018). Therapeutic nurse-client relationship: Maintaining boundaries [Video]. YouTube. Links to an external site. https://www.youtube.com/watch?v=mCgmyyiZ9ek
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