The Patient Evaluation Information

Objective:

The patient is alert and oriented x 4, to person, place, time, and his situation. He was seen today for an initial evaluation via telehealth with his consent obtained. The patient appearance is clean and very neat. His mood is euthymic, and affect is congruent to his mood. His thought process is logical, and goal directed. She has good judgement and insight. She denies suicidal or homicidal ideations currently. She denies visual but report auditory hallucinations currently

General Appearance: Neat & clean.

Eye contact: Normal.

Psychomotor Activity: Normal.

Orientation: Person. Place. Time. Situation.

Attention: Intact.

           

BEHAVIOR: Cooperative.

SPEECH: Normal.

MOOD: Euthymic. Euphoric.

AFFECT: Appropriate.

THOUGHT PROCESS: Goal Directed, Logical.

THOUGHT CONTENT: Intact.

PERCEPTIONS: Good.

INSIGHT: Good.

JUDGMENT: Good.

COGNITION: Intact.

Language. WNL. Abnormal

MEMORY: None. Immediate. Recent. Remote.

C-SSRS (CURRENT)

1. WISH TO BE DEAD:

have you wished you were dead or wish you could go to sleep and not wake up? NO

if yes, describe:

2. NON-SPECIFIC ACTIVE SUICIDAL THOUGHTS:

have you had any thoughts of killing yourself? Yes.

if yes, describe:

3. ACTIVE SUICIDAL IDEATIONS WITH ANY METHODS (NOT PLAN) WITHOUT INTENT TO ACT

have you been thinking about how you might do this? No

if yes, describe:

4. ACTIVE SUICIDAL IDEATIONS WITH SOME INTENTS TO ACT, WITHOUT SPECIFIC PLAN

have you had these thoughts and had some intentions of acting on them? No

if yes, describe:

5.ACTIVE SUICIDAL IDEATIONS WITH SPECIFIC PLAN AND INTENT

have you start to work out or worked out the details of how to kill yourself? No

if yes, describe:

C-SSRS (LIFETIME)

1. WISH TO BE DEAD.

have you wished you were dead or wish you could go to sleep and not wake up? No

if yes, describe:  

2. NON-SPECIFIC ACTIVE SUICIDAL THOUGHTS: In the past, not now.

have you had any thoughts of killing yourself? YES

if yes, describe:

3. ACTIVE SUICIDAL IDEATIONS WITH ANY METHODS (NOT PLAN) WITHOUT INTENT TO ACT

have you been thinking about how you might do this? No

if yes, describe: Pills

4. ACTIVE SUICIDAL IDEATIONS WITH SOME INTENTS TO ACT, WITHOUT SPECIFIC PLAN.

have you had these thoughts and had some intentions of acting on them? YES

if yes, describe: Opened window and thought of jumping out of the window

5.ACTIVE SUICIDAL IDEATIONS WITH SPECIFIC PLAN AND INTENT: NO

have you start to work out or worked out the details of how to kill yourself? No

if yes, describe:

PROTECTIVE FACTORS: Family (Father and stepmother)

RISK ASSESSMENT: Low

SAFETY PLAN RECOMMENDATIONS: TO CALL 911 IF FEELING SUICIDAL

Psychosis: Y/N No

Diagnosis Formulation: Bipolar Disorder.

Score on Administered Screening Tool: PHQ score 10/27

Subjective

The patient is an 18-year-old male in for an initial psychiatric evaluation with consent. He is accompanied by his father and stepmother for the evaluation. Marc reports feeling good right now; he states, " I was diagnosed with ADHD and Bipolar disorder, I am taking Seroquel 50mg and stopped taking Adderall 3 years ago". They report wanting to with a new psychiatrist because the other did not have counseling services.

Assessment

The patient is in for an initial psychiatric evaluation; he reports a previous diagnosis of bipolar disorder and ADHD, and actively taking Seroquel 50mg at night. Patient reports feeling good and having no concerns but wanting continuation of care due to lack of available therapy at his previous provider.

Patient reports a troubled upbringing with divorced parents, expulsion from middle school, bullying, arguments with his mother, and occasional thoughts of suicide in the past.

He reports auditory hallucinations stating where he would see a window and think about jumping out of the window but did not act on the hallucination. A recommendation to increase his prescribed Seroquel to 75mg based on his reported auditory hallucinations and poor sleep was made to patient, however, he declined to increase the dosage stating he is okay. He is educated that if these auditory hallucinations persist and cause him to enact harm on himself or others, he should call 911.

Patient will continue Seroquel 50 mg nightly, and a referral for psychotherapy will be escalated. He is educated on medication compliance to improve his mood symptoms. He is educated on medication side effects and adverse effects. Education is provided on positive coping mechanisms to improve his mood.

A discussion was held with Marc's father who is present during the interview. He expresses his wish to start patient back on his Adderall as he is about to enter college. The father is educated that Adderall will not be prescribed at this time because patient may be able to make behavioral adjustments through psychotherapy sessions and increased engagement in other activities. A reevaluation will be needed to diagnose patient with ADHD. Otherwise, his father is encouraged to continue actively supporting and maintaining open communication with patient.

Plan of Care:

Client will have decreased mood symptoms within 90 days

Client is referred for psychotherapy sessions weekly

Client will continue Seroquel 50mg at bedtime

Client is educated on medication side effects and adverse effects

Follow up in 2 weeks on 3/29/22

Call 911 for suicidal or homicidal ideations

,

Focused SOAP Note and Patient Case Presentation

Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Focused SOAP 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 three weeks, using the Focused SOAP 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. 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 of any age (either a child or an adult) that you examined during the last 3 weeks.

· Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.

· Please Note:

· All SOAP notes must be signed, and each page must be initialed by your Preceptor. Note: Electronic signatures are not accepted.

· When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor.

· You must submit your SOAP note using SafeAssign. Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.

· Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record.

· Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.

· 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. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.

· 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. Specifically address the following for the patient, using your SOAP note as a guide:

·

· Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is 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 their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.

· Plan: What was your plan for psychotherapy? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also be sure to include at least one health promotion activity and one patient education strategy.

· Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.

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Rubric Detail

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

Content

Name: PRAC_6665_Week3_Assignment2_Rubric

• Grid View
• List View

	Excellent	Good	Fair	Poor
Photo ID display and professional attire	Points: Points Range: 5 (5%) – 5 (5%) Photo ID is displayed. The student is dressed professionally. Feedback:	Points: Points Range: 0 (0%) – 0 (0%) Feedback:	Points: Points Range: 0 (0%) – 0 (0%) Feedback:	Points: Points Range: 0 (0%) – 0 (0%) Photo ID is not displayed. Student must remedy this before grade is posted. The student is not dressed professionally. Feedback:
Time	Points: Points Range: 5 (5%) – 5 (5%) The video does not exceed the 8-minute time limit. Feedback:	Points: Points Range: 0 (0%) – 0 (0%) Feedback:	Points: Points Range: 0 (0%) – 0 (0%) Feedback:	Points: Points Range: 0 (0%) – 0 (0%) The video exceeds the 8-minute time limit. (Note: Information presented after 8 minutes will not be evaluated for grade inclusion.) Feedback:
Discuss Subjective data: • Chief complaint • History of present illness (HPI) • Medications • Psychotherapy or previous psychiatric diagnosis • Pertinent histories and/or ROS	Points: Points Range: 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. Feedback:	Points: Points Range: 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. Feedback:	Points: Points Range: 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. Feedback:	Points: Points Range: 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. Feedback:
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	Points: Points Range: 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. Feedback:	Points: Points Range: 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. Feedback:	Points: Points Range: 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. Feedback:	Points: Points Range: 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. Feedback:
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.	Points: Points Range: 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. Feedback:	Points: Points Range: 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. Feedback:	Points: Points Range: 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. Feedback:	Points: Points Range: 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. Feedback:
Discuss treatment Plan: • A treatment plan for the patient that addresses psychotherapy; one health promotion activity and one patient education strategy; plan for treatment and management, including alternative therapies; pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters; and a rationale for the approaches selected.	Points: Points Range: 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, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear and concise rationale for the treatment approaches recommended is provided. Feedback:	Points: Points Range: 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, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear rationale for the treatment approaches recommended is provided. Feedback:	Points: Points Range: 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. Feedback:	Points: Points Range: 0 (0%) – 13 (13%) The response does not address the diagnosis or is missing elements of the treatment plan. Feedback:
Reflect on this case. Discuss what you learned and what you might do differently.	Points: Points Range: 5 (5%) – 5 (5%) Reflections are thorough, thoughtful, and demonstrate critical thinking. Feedback:	Points: Points Range: 4 (4%) – 4 (4%) Reflections demonstrate critical thinking. Feedback:	Points: Points Range: 3.5 (3.5%) – 3.5 (3.5%) Reflections are somewhat general or do not demonstrate critical thinking. Feedback:	Points: Points Range: 0 (0%) – 3 (3%) Reflections are incomplete, inaccurate, or missing. Feedback:
Focused SOAP Note documentation	Points: Points Range: 18 (18%) – 20 (20%) The response clearly, accurately, and thoroughly follows the Focused SOAP Note format to document the selected patient case. Feedback:	Points: Points Range: 16 (16%) – 17 (17%) The response accurately follows the Focused SOAP Note format to document the selected patient case. Feedback:	Points: Points Range: 14 (14%) – 15 (15%) The response follows the Focused SOAP Note format to document the selected patient case, with some vagueness and inaccuracy. Feedback:	Points: Points Range: 0 (0%) – 13 (13%) The response incompletely and inaccurately follows the Focused SOAP Note format to document the selected patient case. Feedback:
Presentation style	Points: Points Range: 5 (5%) – 5 (5%) Presentation style is exceptionally clear, professional, and focused. Feedback:	Points: Points Range: 4 (4%) – 4 (4%) Presentation style is clear, professional, and focused. Feedback:	Points: Points Range: 3.5 (3.5%) – 3.5 (3.5%) Presentation style is mostly clear, professional, and focused Feedback:	Points: Points Range: 0 (0%) – 3 (3%) Presentation style is unclear, unprofessional, and/or unfocused. Feedback:

Show Descriptions Show Feedback

Photo ID display and professional attire–

Levels of Achievement: 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. Feedback:

Time–

Levels of Achievement: 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%) – 0 (0%) The video exceeds the 8-minute time limit. (Note: Information presented after 8 minutes will not be evaluated for grade inclusion.) Feedback:

Discuss Subjective data: • Chief complaint • History of present illness (HPI) • Medications • Psychotherapy or previous psychiatric diagnosis • Pertinent histories and/or ROS —

Levels of Achievement: 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. Feedback:

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–

Levels of Achievement: 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. Feedback:

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.–

Levels of Achievement: 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. Feedback:

Discuss treatment Plan: • A treatment plan for the patient that addresses psychotherapy; one health promotion activity and one patient education strategy; plan for treatment and management, including alternative therapies; pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters; and a rationale for the approaches selected.–

Levels of Achievement: 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, pharmacologic and 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, pharmacologic and 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 t

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