Compose a written comprehensive psychiatric evaluation of an adolescent patient you have seen in the clinic

Compose a written comprehensive psychiatric evaluation of an adolescent patient you have seen in the clinic

Step 1: You will use the: Graduate Comprehensive Psychiatric Evaluation Template

  1. Compose a written comprehensive psychiatric evaluation of an adolescent patient you have seen in the clinic.
    • Your preceptor MUST sign their initials on the comprehensive psychiatric evaluation document to confirm they have reviewed and acknowledged this patient was seen in their clinic.
  2. You will then use Canvas Studio Screen Capture and Webcam (I want to see your face and your document at the same time) to record yourself presenting your completed comprehensive psychiatric evaluation document.
    • Use ONLY Canvas Studio to record your comprehensive psychiatric evaluation and verbal presentation. No other medium will be accepted.

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.

S =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)
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
A =Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes
P =Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and a follow up

Other: Incorporate current clinical guidelines NIH Clinical Guidelines or APA Clinical Guidelines, research articles, and the role of the PMHNP in your presentation.

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

Successfully Capture HPI Elements in Psychiatry E/M Notes
AAPC Admin. (2013, August 1). Successfully capture HPI elements in psychiatry E/M notes. Advancing the Business of Healthcare. https://www.aapc.com/blog/25848-successfully-captu…

Submission Instructions:

  • The presentation is original work and logically organized, formatted, and cited in the current APA style, including citation of references.
  • Upload your completed Comprehensive Psychiatric Evaluation as word document
  • Then, have your preceptor sign and date your completed Comprehensive Psychiatric Evaluation, on the comprehensive psychiatric evaluation document to confirm they have reviewed and acknowledge this patient was seen in their clinic.
  • No typed signatures will be accepted. Secure your preceptor’s signature in time for your presentation.
  • 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).
  • You will use this signed template for your video presentation. The signature should be visible by faculty during your presentation (you should also state this is my preceptor’s signature) during your presentation.
  • The presentation should be less than 7 minutes in length. 
  • You must show your identification at the beginning of the presentation, or the presentation will not be graded.
  • You must wear your lab coat and conduct the video in a professional setting, or the presentation will not be graded.
  • You must submit upload your document to Canvas
  • You will submit the link to your video presentation as a comment in the assignment portion of the course
  • Complete and submit the assignment by 11:59 PM ET Sunday.

Grading Rubric

Your assignment will be graded according to the grading rubric.

View Rubric

NUR 630CL Video Case Presentation and Psychiatric SOAP Note Rubric 2022
NUR 630CL Video Case Presentation and Psychiatric SOAP Note Rubric 2022
CriteriaRatingsPts
Chief Complaint view longer description4 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 view longer description2 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 view longer description5 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 view longer description2 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, student does not list each type of drug, environmental factor, herbal, food, latex name and include severity of allergy OR description of the allergy 1 pts Developing If allergies are present, student only lists the type of allergy and omits the name of the allergy 0 pts Novice Information is completely missing/ 2 pts
Review of Systems (ROS) – S view longer description5 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 view longer description2 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 view longer description3 pts Exemplary During the visit: 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 During the visit: 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 During the visit: 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
Medications-S view longer description3 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) 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) 1 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/ 3 pts
Past Medical History-S view longer description3 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
Past Psychiatric History-S view longer description3 pts Exemplary Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), year of diagnosis and 2 pts Distinguished Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (omits addiction treatment), year of diagnosis 1 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/ 3 pts
Family Psychiatric History-S view longer description3 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 view longer description3 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
Mental Status Exam-O view longer description15 to >10 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 10 to >5 pts Distinguished Includes all 8 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 5 to >0 pts Developing Includes >6 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with some descriptions for each area 0 pts Novice Includes <3 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) OR detailed descriptions is not included for each area/ 15 pts
Primary Diagnoses-A view longer description8 to >4 pts Exemplary Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority) 4 to >2 pts Distinguished Includes a clear outline of the accurate diagnoses addressed at the visit but does not list the diagnoses in descending order of priority 2 to >0 pts Developing Includes an inaccurate diagnosis as the principal diagnosis 0 pts Novice Information is completely missing/ 8 pts
Differential Diagnoses-A view longer description3 pts Exemplary Includes at least 2 differential diagnoses that can be supported by the subjective and objective data provided. 2 pts Distinguished Includes 1 differential diagnosis that can be supported by the subjective and objective data provided. 1 pts Developing Includes at least 1 differential diagnosis that is NOT supported by the subjective and objective data 0 pts Novice Information is completely missing/ 3 pts
Outcome Labs/Screening Tools – O view longer description3 pts Exemplary After the visit: orders appropriate diagnostic/lab testing or screening tool 100% of the time OR acknowledges “no diagnostic testing or screening tool clinically required at this time” 2 pts Distinguished After the visit: orders appropriate diagnostic/lab testing 50% of the time OR acknowledges “no diagnostic testing or screening tool clinically required at this time” 1 pts Developing After the visit, orders appropriate diagnostic testing less than 50% of the time. 0 pts Novice Information is completely missing./ 3 pts
Treatment view longer description10 to >7.5 pts Exemplary Includes a detailed pharmacologic and non pharmacological treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the following: drug/vitamin/herbal name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. For non-pharmacological treatment, includes: treatment name, frequency, duration. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. The plan is supported by the current US clinical guidelines. 7.5 to >3.5 pts Distinguished Includes a detailed pharmacologic and non pharmacological treatment plan for each of the diagnoses listed under “assessment”. The plan includes 4-7 of the following: drug/vitamin/herbal name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. For non-pharmacological treatment, includes: treatment name, frequency, duration. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. The plan is supported by the current US clinical guidelines. 3.5 to >0 pts Developing Includes a detailed pharmacologic and non pharmacological treatment plan for each of the diagnoses listed under “assessment”. The plan includes 4 of the following: drug/vitamin/herbal name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. Non-pharmacological treatment NOT included. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. The plan is NOT supported by the current US clinical guidelines OR is unsafe. 0 pts Novice Information is completely missing/ 10 pts
Patient/Family Education-P view longer description5 to >3 pts Exemplary Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives. 3 to >2 pts Distinguished Includes at least 2 strategies to promote and develop skills for managing their illness and at least 2 self-management methods on how to incorporate healthy behaviors into their lives. 2 to >0 pts Developing Includes at least 1 strategies to promote and develop skills for managing their illness and at least 1 self-management methods on how to incorporate healthy behaviors into their lives. 0 pts Novice Information is completely missing./ 5 pts
Referral view longer description3 pts Exemplary Provides a detailed list of medical and other interdisciplinary referrals or documents NO REFERRAL ADVISED AT THIS TIME. Includes a timeline for follow up appointments. 2 pts Distinguished Provides a medical or other interdisciplinary referral or documents NO REFERRAL ADVISED AT THIS TIME. Includes a timeline for follow up appointments. 1 pts Developing Provides a medical or other interdisciplinary referral. DOES NOT include a timeline for follow up appointments. 0 pts Novice Information is completely missing./ 3 pts
APA Formatting view longer description5 to >3 pts Exemplary Effectively uses literature and other resources to inform their work. Exceptional use of citations and extended referencing. High level of precision with APA 7th Edition writing style. 3 to >2 pts Distinguished Effectively uses literature and other resources to inform their work. Moderate use of citations and extended referencing. Moderate level of precision with APA 7th Edition writing style. 2 to >0 pts Developing Ineffectively uses literature and other resources to inform their work. Moderate use of citations and extended referencing. APA 7th Edition writing style not strictly adhered to. 0 pts Novice APA style and writing mechanics not used./ 5 pts
Audio-Video Presentation view longer description5 to >3.5 pts Exemplary Audio-Video presentation contains the signed copy of the psychiatric soap note with references. Well-rehearsed. Voice, eye contact and pacing hold interest and attention of the audience; introduced self and clinical case. 3.5 to >1.5 pts Distinguished Audio-Video presentation contains the clinical psychiatric note but it was not signed or the references were missing. Fairly fluid delivery. Communicates ideas with proper voice projection; perhaps one mispronounced work; made eye contact 1.5 to >0 pts Developing Audio-Video presentation contains a signed psychiatric note but does not include the references. The presentation does not accurately portray the therapeutic intervention or content of the presentation. Some difficulty communicating ideas. Poor voice projections; some eye contact; no introduction; mispronounced a few words; long pauses; somewhat confused. 0 pts Novice Audio-Video presentation was not submitted or the video was not created using the audio or video platform required in the instructions. Great difficulty communicating ideas. Poor voice projection; no eye contact; no introduction; mispronounced words; stopped or had long pauses; read from notes/ 5 pts
References view longer description5 to >3.33 pts Exemplary 2 pts Distinguished The reference page contains at least the required current scholarly academic reference and text reference. Follows APA guidelines of components: double space, 12 pt. font, abstract, level headings, hanging indent and in-text citations. 3.33 to >1.67 pts Distinguished References page contains one current scholarly academic resource and text reference. Follows most APA guidelines of components: double space, 12 pt. font, abstract, level headings, hanging indent, and in-text citations 1.67 to >0 pts Developing References page contains one current or outdated scholarly academic resource. Many errors of APA guidelines: double space, 12 pt. font, abstract, level headings, hanging indent, and in-text citations. 0 pts Novice References page contains no current scholarly academic resources, only internet webpages or no reference page. Lack of APA guidelines for references provided or in-text citations./ 5 pts

Requirements: Fill the template

You know the drill just fill the template creating a case of an adolescent in psychiatry. And for reference I live in Miami, FL.

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comprehensive psychiatric evaluation

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