St Thomas University Comprehensive Evaluation Presentation
Description
Comprehensive Psychiatric Evaluation 2
Step 1: For this assignment, students will create a video presentation using a patient they have seen in the clinic. Use Canvas Studio’s Screen Capture feature to record (voice and video) your presentation. No other medium will be accepted. Instructions on creating the video are listed below:
Step 2: Each student will create a focused SOAP note PowerPoint presentation. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive psychiatric SOAP note is to be written using the attached template below.
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Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS) |
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O = |
Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam, (Focused), and Mental Status Exam |
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Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes |
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Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up |
Other: Incorporate current clinical guidelines NIH Clinical Guidelines (Links to an external site.)or APA Clinical Guidelines (Links to an external site.), research articles, and the role of the PMHNP in your presentation.
- Psychiatric Assessment of Infants and Toddlers (Links to an external site.)
- Psychiatric Assessment of Children and Adolescents (Links to an external site.)
Reminder: It is important that you complete this assessment using your critical thinking skills. You are expected to synthesis your clinical assessment, formulate a psychiatric diagnosis, and develop a treatment plan independently. It is not acceptable to document “my preceptor made this diagnosis.” An example of the appropriate descriptors of the clinical evaluation is listed below. It is not acceptable to document “within normal limits.”
Graduate Mental Status Exam Guide.docx
Submission Instructions:
The presentation is original work and logically organized, formatted, and cited in the current APA style, including citation of references.
The presentation should consist of 10-15 slides and less than 7 minutes in length (excluding the introduction and reference page).
Incorporate a minimum of four current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work. Journal articles and books should be referenced according to APA style, 7th Edition (the library has a copy of the APA Manual).
Students must show their identification at the beginning of the presentation, or the presentation will not be graded.
Students must wear their lab coats and conduct the video in a professional setting, or the presentation will not be graded.
Complete and submit the assignment by 11:59 PM ET Sunday
| Psychiatric SOAP Note Rubric | ||
|---|---|---|
| Criteria | Ratings | Pts |
| Chief Complaint |
4 to >3 pts Exemplary Includes a direct quote from patient about presenting problem 3 to >2 pts Distinguished Includes a direct quote from patient and other unrelated information 2 to >0 pts Developing Includes information but information is NOT a direct quote 0 pts Novice Information is completely missing |
/ 4 pts |
|
Demographics – S |
2 pts Exemplary Begins with patient initials, age, race, ethnicity, and gender (5 demographics) 1.5 pts Distinguished Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity, and gender) 1 pts Developing Begins with 3 or less patient demographics (patient initials, age, race, ethnicity, and gender) 0 pts Novice Information is completely missing |
/ 2 pts |
|
History of the Present Illness (HPI) – S |
5 to >3 pts Exemplary Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity) 3 to >2 pts Distinguished Includes the presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing 2 to >1 pts Developing Includes the presenting problem and 4 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing 1 to >0 pts Novice The presenting problem is not clearly stated and/or there are < 4 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing |
/ 5 pts |
|
Allergies – S |
2 pts Exemplary Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy) 1.5 pts Distinguished If allergies are present, students list type Drug, environmental factor, herbal, food, latex name and include severity of allergy OR description of the allergy 1 pts Developing If allergies are present, students lists only the type of allergy name 0 pts Novice Information is completely missing |
/ 2 pts |
|
Review of Systems (ROS) – S |
5 to >3 pts Exemplary Includes a minimum of 3 assessments for each body system, assesses at least 9 body systems directed to chief complaint, AND uses the words “admits” and “denies” 3 to >2 pts Distinguished Includes 3 or fewer assessments for each body system, assesses 5-8 body systems directed to chief complaint, AND uses the words “admits” and “denies” 2 to >0 pts Developing Includes 3 or fewer assessments for each body system, and assesses less than 5 body systems directed to chief complaint, OR student does not use the words “admits” and “denies” 0 pts Novice Information is completely missing |
/ 5 pts |
|
Vital Signs – O |
2 pts Exemplary Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.) 1.5 pts Distinguished Includes at least 6 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.) 1 pts Developing Includes at least 4 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.) 0 pts Novice Information is completely missing |
/ 2 pts |
|
Labs, Diagnostic Tests and Screening Tools – O |
3 pts Exemplary Includes a list of the labs, diagnostic tests or screening tools reviewed at the visit, values of lab results or screening tools, and highlights abnormal values, OR acknowledges no labs/diagnostic tests were reviewed. 2 pts Distinguished Includes a list of the labs, diagnostic tests, or screening tools reviewed at the visit, but does not include the values of lab results or screening tools, but does not highlight abnormal values. 1 pts Developing Includes a list of the labs, diagnostic tests, or screening tools reviewed at the visit but does not include the values of the results or highlight abnormal values. 0 pts Novice Information is completely missing. |
/ 3 pts |
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Medications-S |
4 to >3 pts Exemplary Includes a list of all of the patient reported psychiatric and medical medications and the diagnosis for the medication (including name, dose, route, frequency) 3 to >2 pts Distinguished Includes a list of all of the patient reported psychiatric and but omits the medical medications and the diagnosis for the medication (including name, dose, route, frequency) 2 to >0 pts Developing Includes a list of some of the patient reported psychiatric and/or medical medications and the diagnosis for the medication (omits the dose, route, frequency of the medications) 0 pts Novice Information is completely missing |
/ 4 pts |
|
Past Medical History-S |
3 pts Exemplary Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current 2 pts Distinguished Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current 1 pts Developing Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current 0 pts Novice Information is completely missing |
/ 3 pts |
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Past Psychiatric History-S |
5 to >3 pts Exemplary Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), year of diagnosis and 3 to >2 pts Distinguished Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (omits addiction treatment), year of diagnosis 2 to >0 pts Developing Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), does not include the year of diagnosis 0 pts Novice The information is completely missing |
/ 5 pts |
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Family Psychiatric History-S |
3 pts Exemplary Includes an assessment of at least 6 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder and history of suicidal attempts 2 pts Distinguished Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder and history of suicidal attempts 1 pts Developing Includes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder and history of suicidal attempts 0 pts Novice Information is completely missing |
/ 3 pts |
|
Social History-S |
3 pts Exemplary Distinguished Includes all 11 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation. 2 pts Distinguished Includes at least 8 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation. 1 pts Developing Includes all 6 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation. 0 pts Novice Information is completely missing. |
/ 3 pts |
|
Physical Examination-O |
3 pts Exemplary Includes a minimum of 3 assessments for each body system and assesses at least 5 body systems directed to chief complaint 2 pts Distinguished Includes a minimum of3 assessments for each body system and assesses at least 4 body systems directed to chief complaint 1 pts Developing Includes a minimum of 2 assessments for each body system and assesses at least 4 body systems directed to chief complaint 0 pts Novice Information is completely missing |
/ 3 pts |
|
Mental Status Exam-O |
15 to >8 pts Exemplary Includes all 10 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with detailed descriptions for each area 8 to >5 pts Distinguished Includes all 8 components of Have a similar assignment? "Place an order for your assignment and have exceptional work written by our team of experts, guaranteeing you A results."
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