Posted: January 28th, 2022

Comprehensive Psychiatric Evat6luation Note and Patient Case Presentation

Comprehensive Psychiatric Evaluation Note and Patient Case Presentation

Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. 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 at your practicum site, using the Comprehensive Psychiatric Evaluation 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 about impulse-control and conduct disorders.
• Select a patient for whom you conducted psychotherapy for an impulse control or conduct disorder during the last 6 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, and each page must be initialed by your Preceptor. When you submit your note, you should include the complete comprehensive evaluation note as a Word document and pdf/images of each page that is initialed and signed by your Preceptor. You must submit your note using SafeAssign.
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 Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
• 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 study for your clinical patient. In your
presentation:

• Dress professionally with a lab coat 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.
o 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?
o Objective: What observations did you make during the psychiatric assessment?
o Assessment: Assignment help – 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 diagnostic criteria and is supported by the patient’s symptoms.
o Plan: What was your plan for psychotherapy (including one health promotion activity and one patient education strategy)? What was your plan for treatment and management, including alternative therapies? Include nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
o Reflection notes: What would you do differently with this patient if you could conduct the session again?
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Detachment
Change the rubric’s layout by choosing Grid or List.

PRAC 6645 Week7 Rubric

View Grid List

Excellent Good Fair Poor
Photo ID and business attire
Points: 5 (5 percent ) 5 (5 percent )
Photo ID is shown. The pupil is properly attired.
0 – 0 (0 percent )
0 – 0 (0 percent )
0 – 0 (0 percent )
No photo ID is shown. Student must fix before grade is posted. The student is not properly attired.
Feedback: sTime
Points: 5 (5 percent ) 5 (5 percent )
The video is within the 8-minute restriction.
0 – 0 (0 percent )
0 – 0 (0 percent )
Range: 0 – 3 (3 percent )
The video is longer than 8 minutes. (Note: Information delivered after 8 minutes is not graded.)
Feedback: sAssignment help – Discuss Observations:
• Medications • History of current illness (HPI)
• Previous psychiatric or psychotherapy
• Relevant histories or ROS
Points: 9 (9 percent ) 10 (10 percent )
To aid in differential diagnosis, the film accurately and concisely portrays the patient’s subjective complaint, current illness history, drugs, psychotherapy, or previous psychiatric diagnosis.
8 (8%) – 8 (8 percent )
The film accurately portrays the patient’s subjective complaint, current illness, drugs, psychotherapy, or previous psychiatric diagnosis, as well as relevant histories and/or system reviews.
7 (7%) – 7 (7 percent )
To aid in differential diagnosis, the video depicts the patient’s subjective complaint and history of current illness, drugs, psychotherapy and/or past psychiatric diagnosis, but is ambiguous or contains small mistakes.
Range: 0 – 6 (6 percent )
There is no mention of the patient’s subjective complaint, current illness, medications, psychotherapy, previous psychiatric diagnosis, or relevant histories and/or assessment of systems that would aid in differential diagnosis. Or no subjective documentation.
Feedback: sAssignment help – Discuss Observations:
• Physical exam documentation of relevant systems, HPI, and history
• All diagnostic results required to create differential diagnoses (lab, imaging, etc.)
9 – 10 (10 percent )
The video captures the patient’s physical assessment for relevant systems. Relevant diagnostic tests and their outcomes are documented.
8 (8%) – 8 (8 percent )
The response accurately records the patient’s physical exam. The outcomes of diagnostic tests are noted.
7 (7%) – 7 (7 percent )
The patient’s physical exam documentation is imprecise or inaccurate. The findings of diagnostic testing are recorded but are inaccurate.
Range: 0 – 6 (6 percent )
The response offers incomplete, erroneous, or overly detailed/verbose physical exam paperwork. Unnecessary system reviews or lack of objective documentation.
Feedback:
Assess the results:
• Mental status examination results
• List three possible diagnoses in order of priority and explain your choices. What was your initial diagnosis? Describe how your primary diagnosis meets DSM-5 criteria and is backed up by symptoms.

Detailed Psychiatric Evaluation and Patient Case Report

Psychiatric notes allow you to reflect on your practicum experiences and link them to your weekly Learning Resources. This practicum course’s comprehensive mental evaluation notes are frequently utilized in clinical settings to document patient care.

Use the Comprehensive Psychiatric Evaluation Note Template to document information about a patient you examined during your practicum. Incorporate the information into a case presentation for this patient.

Prepared
Study this week’s Learning Resources for insights on impulse control and conduct disorders.
•
Select a patient with whom you have recently treated an impulse control or behavior disorder. Formalize this patient’s evaluation using the Learning Resources’ framework. A completed template is included as an example and guide. Your Preceptor must sign and initial all mental examination notes. When submitting your evaluation letter, send a Word document with a pdf/image of each page initialed and signed by your Preceptor. Submit your note via SafeAssign.
No electronic signatures accepted. If the files are not received by the due date, the Faculty shall deduct points.
•
Then create a video case presentation based on your patient examination. Prepare your presentation following the Assignment rubric and practice it. Use the Kaltura Media Uploader resource in the classroom’s left navigation to create your own Kaltura video.
• List five scholarly references to support your judgment and diagnosis.
• Ensure you have adequate lighting and recording equipment.

The Task

Record yourself presenting your clinical patient’s challenging situation. In your talk:

• Wear a lab coat and show oneself professionally.
• When introducing oneself, provide your photo ID.
(i.e., don’t use the patient’s name or any other identifying information.)
• Present the entire case study. Keep your presentation to 8 minutes or less. Present psychiatric diagnosis, including differentials ruled out, current psychotherapy plan (including one health promotion activity and one patient education method you gave), and patient progress toward treatment goals.
o Subjective: What information did the patient provide about their major complaint and symptoms? How long and how severe were their symptoms? How do their illnesses affect their daily lives?
o What did you notice throughout the psychological evaluation?
o Mental Status Exam: Assignment help – Discuss the patient’s results. What was your differential? List three possible diagnoses in order of priority and explain your choices. What was your initial diagnosis? Describing your primary diagnosis in terms of DSM-5 diagnostic criteria and symptoms is important.
o Plan: What was your plan for psychotherapy (including one health promotion activity and one patient education strategy)? What was your plan for treatment and management, including alternative therapies? Include nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
o Reflection notes: What would you do differently with this patient if you could conduct the session again?

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