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Name: PRAC_6675_Week4_Discussion_Participant_Rubric

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	Excellent	Good	Fair	Poor
Responses	Points: Points Range: 77 (77%) – 85 (85%) Responses exhibit synthesis, critical thinking, and application to practice settings. Responses provide clear, concise opinions and ideas that are supported by at least two scholarly sources. Responses demonstrate synthesis and understanding of Learning Objectives. Communication is professional and respectful to colleagues. Presenters' prompts/questions posed in the case presentations are thoroughly addressed. Responses are effectively written in standard, edited English. Feedback:	Points: Points Range: 68 (68%) – 76 (76%) Responses exhibit critical thinking and application to practice settings. Responses provide clear, concise opinions and ideas that are supported by 2 or more credible sources. Communication is professional and respectful to colleagues. Presenters' prompts/questions posed in the case presentations are addressed. Responses are effectively written in standard, edited English. Feedback:	Points: Points Range: 60 (60%) – 67 (67%) Responses are on topic and may have some depth. Responses may lack clear, concise opinions and ideas, and only one or no credible sources are cited. Responses posted in the Discussion may lack effective professional communication. Presenters' prompts/questions posed in the case presentations are inadequately addressed. Feedback:	Points: Points Range: 0 (0%) – 59 (59%) Responses may not be on topic and lack depth. No credible sources are cited. Responses posted in the Discussion lack effective professional communication. Responses to colleagues’ prompts/questions are missing. Feedback:
Participation	Points: Points Range: 14 (14%) – 15 (15%) Meets requirements for participation by responding at least twice to each colleague who presented this week. Responses are carried out over multiple days between Days 4 and 7. Feedback:	Points: Points Range: 12 (12%) – 13 (13%) Meets requirements for participation by responding at least twice to each colleague who presented this week, over at least 2 days. Feedback:	Points: Points Range: 11 (11%) – 11 (11%) Participants respond at least twice to each colleague who presented this week, but responses may occur all in 1 day. Feedback:	Points: Points Range: 0 (0%) – 10 (10%) Does not meet requirements for participation by responding at least twice to each colleague who presented this week. Feedback:

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Responses–

Levels of Achievement: Excellent 77 (77%) – 85 (85%) Responses exhibit synthesis, critical thinking, and application to practice settings. Responses provide clear, concise opinions and ideas that are supported by at least two scholarly sources. Responses demonstrate synthesis and understanding of Learning Objectives. Communication is professional and respectful to colleagues. Presenters' prompts/questions posed in the case presentations are thoroughly addressed. Responses are effectively written in standard, edited English. Good 68 (68%) – 76 (76%) Responses exhibit critical thinking and application to practice settings. Responses provide clear, concise opinions and ideas that are supported by 2 or more credible sources. Communication is professional and respectful to colleagues. Presenters' prompts/questions posed in the case presentations are addressed. Responses are effectively written in standard, edited English. Fair 60 (60%) – 67 (67%) Responses are on topic and may have some depth. Responses may lack clear, concise opinions and ideas, and only one or no credible sources are cited. Responses posted in the Discussion may lack effective professional communication. Presenters' prompts/questions posed in the case presentations are inadequately addressed. Poor 0 (0%) – 59 (59%) Responses may not be on topic and lack depth. No credible sources are cited. Responses posted in the Discussion lack effective professional communication. Responses to colleagues’ prompts/questions are missing. Feedback:

Participation–

Levels of Achievement: Excellent 14 (14%) – 15 (15%) Meets requirements for participation by responding at least twice to each colleague who presented this week. Responses are carried out over multiple days between Days 4 and 7. Good 12 (12%) – 13 (13%) Meets requirements for participation by responding at least twice to each colleague who presented this week, over at least 2 days. Fair 11 (11%) – 11 (11%) Participants respond at least twice to each colleague who presented this week, but responses may occur all in 1 day. Poor 0 (0%) – 10 (10%) Does not meet requirements for participation by responding at least twice to each colleague who presented this week. Feedback:

Total Points: 100

Name: PRAC_6675_Week4_Discussion_Participant_Rubric

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Week (enter week #): (Enter assignment title)

Student Name

College of Nursing-PMHNP, Walden University

PRAC 6675: PMHNP Care Across the Lifespan II

Faculty Name

Assignment Due Date

Subjective:

CC (chief complaint):

HPI:

Substance Current Use:

Medical History:

· Current Medications:

· Allergies:

· Reproductive Hx:

ROS:

· GENERAL:

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:

Diagnostic Impression:

Reflections:

Case Formulation and Treatment Plan: 

References

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NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar

INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY

If you are struggling with the format or remembering what to include, follow the Focused SOAP Note Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. After reviewing full details of the rubric, you can use it as a guide.

In the Subjective section, provide:

· Chief complaint

· History of present illness (HPI)

· Past psychiatric history

· Medication trials and current medications

· Psychotherapy or previous psychiatric diagnosis

· Pertinent substance use, family psychiatric/substance use, social, and medical history

· Allergies

· ROS

Read rating descriptions to see the grading standards!

In the Objective section, provide:

· 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.

Read rating descriptions to see the grading standards!

In the Assessment section, provide:

· Results of the mental status examination, presented in paragraph form.

· At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case .

· Read rating descriptions to see the grading standards!

Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations ( demonstrate critical thinking beyond confidentiality and consent for treatment !), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

(The FOCUSED SOAP psychiatric evaluation is typically the follow-up visit patient note. You will practice writing this type of note in this course. You will be focusing more on the symptoms from your differential diagnosis from the comprehensive psychiatric evaluation narrowing to your diagnostic impression. You will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)

EXEMPLAR BEGINS HERE

Subjective:

CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:

N.M. is a 34-year-old Asian male presents for medication management follow up for anxiety. He was initiated sertraline last appt which he finds was effective for two weeks then symptoms began to return.

Or

P.H., a 16-year-old Hispanic female, presents for follow up to discuss previous psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications as we deferred until further testing and screening was conducted.

Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.

Paint a picture of what is wrong with the patient. First what is bringing the patient to your follow up evaluation? Document symptom onset, duration, frequency, severity, and impact. What has worsened or improved since last appointment? What stressors are they facing? Your description here will guide your differential diagnoses into your diagnostic impression. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns

ROS: Cover all body systems that may help you include or rule out a differential diagnosis. Please note: THIS IS DIFFERENT from a physical examination!

You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Objective:

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

Assessment:

Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.

He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking.   He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good. 

Diagnostic Impression: You must begin to narrow your differential diagnosis to your diagnostic impression. You must explain how and why (your rationale) you ruled out any of your differential diagnoses. You must explain how and why (your rationale) you concluded to your diagnostic impression. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

Case Formulation and Treatment Plan 

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions including psychotherapy and/or psychopharmacology, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. *See an example below. You will modify to your practice so there may be information excluded/included. If you are completing this for a practicum, what does your preceptor document?

Risks and benefits of medications are discussed including non- treatment. Potential side effects of medications discussed (be detailed in what side effects discussed). Informed client not to stop medication abruptly without discussing with providers. Instructed to call and report any adverse reactions. Discussed risk of medication with pregnancy/fetus, encouraged birth control, discussed if does become pregnant to inform provider as soon as possible. Discussed how some medications might decreased birth control pill, would need back up method (exclude for males).

Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. Discussed how drugs/alcohol affect mental health, physical health, sleep architecture.

Initiation of (list out any medication and why prescribed, any therapy services or referrals to specialist):

Client was encouraged to continue with case management and/or therapy services (if not provided by you)

Client has emergency numbers: Emergency Services 911, the Client's Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)

Reviewed hospital records/therapist records for collaborative information; Reviewed PMP report (only if actually completed)

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (this relates to informed consent; you will need to assess their understanding and agreement)

Follow up with PCP as needed and/or for:

Labs ordered and/or reviewed (write out what diagnostic test ordered, rationale for ordering, and if discussed fasting/non fasting or other patient education)

Return to clinic:

Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care.

References (move to begin on next page)

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

© 2022 Walden University Page 1 of 3

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PATIENT CASE STUDY

Subjective

The patient is a 12-year-old female that is brought in for an initial evaluation by her mother with consent obtained via telehealth. The patient's mother stated that the patient was admitted to Brook Lane inpatient 2 weeks ago for suicidal ideations; she had previously been diagnosed with ADHD and was on Vyvanse and Prozac which they said exacerbated the mood disorder. The mother said that she was properly diagnosed at Brook Lane and was prescribed Lamictal 25mg from the inpatient admission starting on 5/26/22. She has side effects of nausea, but I do feel like she is doing better, she is calmer but before she was restlessness and impulsivity". The patient stated, "I tried to kill myself by cutting and overdosed on Ibuprofen. I don't know how I felt when I was doing it".

Objective:

The patient is alert and oriented x 4, to person, place, and time, and aware of the situation. She presented herself very well. The general appearance is neat and clean, with normal eye contact. Her psychomotor activity is normal with intact attention, though she looks tired and agitated. Her speech is normal, and mood is irritable, and her affect is congruent to her mood. The thought process is linear and gold-directed and thought content is intact. Her perception is fair, insight fair, and cognition is intact. The patient denied suicidal or homicidal ideation presently. She also denies delusions or hallucinations presently.

Assessment

The patient is brought in for an initial evaluation by her mother. The patient is reserved during the interview, and short with her responses. Her mother explains that the patient was previously admitted to an inpatient psychiatric unit for a suicide attempt. In that hospitalization, the patient was diagnosed with a mood disorder and started on Lamictal 25mg. Her mother reports an observable change in her mood, but a side effect of nausea. The PHQ is used, and the patient scored patient scores 19/27. She is currently in therapy and has reportedly established trust with her therapist. She will continue therapy sessions. She will continue taking Lamictal 25mg daily to improve her mood. She will start taking Omega 3 fish oil 300mg daily to aid her cognition and recall. She is educated on medication side effect and interactions; reassured that nausea will subside as the week progress. The patient and mother are encouraged to keep a journal of her high and low moods to discuss during her next follow-up visit. She is educated on positive coping mechanisms to improve her mood. She verbalizes understanding.

Plan of care:

The patient will have an improved mood within the next 90 days.

The patient will continue Lamictal 25mg daily to help with her mood.

The patient will start Omega 3 fish oils 300mg daily.

The patient will continue psychotherapy sessions.

The patient is educated on medication side effects and interactions.

The patient is encouraged to keep journals of high and low moods and bring it to the next follow-up visit for discussion.

The patient is educated on positive coping mechanisms to improve her mood.

Follow up in 4 weeks.

Call 911 for suicidal or homicidal ideations.

Here is the VITAL SIGNS Below:

B/P=113/62, temperature=97.9, Pulse=78, Respiration=18, Oxygen=98%, Weight=101lbs.

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PLEASE FOLLOW THE INSTRUCTIONS AS INDICATED BELOW:

1). ZERO (0) PLAGIARISM.

2). AT LEAST 5 REFERENCES, NO MORE THAN 5 YEARS (WITHIN 5YRS, OR LESS THAN 5YRS)

3). PLEASE SEE THE ATTACHED: Rubric details, Patient’s Case Study and WK2 Assignment 1 Direction/Instruction/Direction.

4). Please review and follow the grading rubric details, and include each component in the assignment as required. Also, follow the APA 7 writing rules and style/Format.

PLEASE TAKE NOTE:

Instructor’s Expectations:

Assignments MUST have a 50% or less on Safe assign.  I have had students fail out of the course in the past for PLAGERISM.

 

SAFE-ASSIGN HAS TO BE LOWER THAN 50%, AND IF IT'S HIGHER AND THERE IS EVIDENCE THAT PAST ASSIGNMENTS WERE REUSED FROM ANOTHER COURSE OR THERE ARE ANY SIGNS OF PLAGIARISM, AN AI INVESTIGATION WILL BE OPEN. 

PLEASE DO NOT HESITATE TO MESSAGE ME FOR ANY CLARIFICATION OR MISUNDERSTANDING OF THE ASSIGNMENT.

Thank you  

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