Clinical Case Presentation Paper
Case Presentation Paper (CO: 1-9): Students are required to complete a case presentation paper guided by a Nursing Theorist or Psychodynamic Theory to inform clinical care. The paper must adhere to APA 7th edition format and will be evaluated for correct grammar, spelling, and overall scholarly writing. A minimum of three current references, published within the past five years, must be used to support clinical reasoning and decision-making. All identifying data should be limited to the individual’s initials to protect confidentiality. The paper must include the following components: identifying data, chief complaint, history of present illness, psychiatric history, personal and social history, mental status examination, suicide/homicide risk assessment, medical history, allergies, current medications, review of systems, history of abuse or trauma, DSM-5-TR diagnosis, application of a nursing theory or psychodynamic approach, treatment plan and goals, education and referrals, conclusions and summary, and a reference list. Emphasis will be placed on the integration of evidence-based data throughout the assessment.
CASE PRESENTATION REQUIREMENTS
1. Please use APA 7th edition format. The paper will be reviewed for correct grammar and spelling. 2. Use a Nursing Theorist or Psychodynamic Theory to guide your care. 3. Must have three current references from the past 5 years. 4. Must include the following elements:
Use of APA 7th edition format and grammar
Identifying data, but only use the individual’s initials
Chief Complaint (CC)
History of Present Illness (HPI)
Psychiatric History and Substance Use History
Personal and Social History
Mental Status Examination
Written Case Presentation
Criteria Ratings Pts
Chief Complaint
5 pts
History of Present Illness 5 pts
Psychiatric History 5 pts
Suicide and Homicide Assessment
Medical History
Allergies
Current Medications
Review of Systems
History of Abuse, Neglect, and Trauma
Mental Status Examination
Assessment i.e. DSM 5-TR Diagnosis
Nursing Theory/Psychodynamic Approach
Treatment Plan and Goals
Education and Referrals
Conclusions and Summary
References page including evidenced-based data
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