For this assignment, students will create a video presentation performing a comprehensive psychiatric evaluation of an infant or toddler
For this assignment, students will create a video presentation performing a comprehensive psychiatric evaluation of an infant or toddler
Step 1: For this assignment, students will create a video presentation performing a comprehensive psychiatric evaluation of an infant or toddler. You are expected to choose a child and an adult to conduct an interview with. The child and parent are not required to be actual clinic patients, but merely someone who has agreed to perform the interview with you. You will be graded on your interview skills when interviewing the persons performing as an infant or toddler and a parent. You are expected to ask the patient and the parent questions the same way you do with your patients in the clinic. Both should be available virtually or in-person to answer questions. You may use a Zoom/video call to assess the simulated patient if you do not have a child/parent you can assess face to face.
I expect that you will conduct a mental status exam during the interview. If you don’t ask it or explain how you observed it, then don’t document it. Only the information asked in the video will be used for grading.
Use the rubric as a guide for collecting data. Don’t miss points because something was not addressed.
Use Canvas Studio’s Screen Capture feature to record (voice and video) your presentation. No other medium will be accepted. Upload the comprehensive psychiatric examination document. Your documentation will be graded on what you asked during the session. The instructions for creating the video are listed below:
Step 2: Each student will create a focused SOAP note or PowerPoint presentation. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive psychiatric SOAP note or PowerPoint is to be written using the attached template below. Do not provide a voiceover or video for the PowerPoint. Only the information asked in the video will be used for grading.
| 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; 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 follow up |
Other: Incorporate current clinical guidelines NIH Clinical Guidelines https://www.nccih.nih.gov/health/providers/clinicalpractice , research articles, and the role of the PMHNP in your presentation.
- Psychiatric Assessment of Infants and Toddlers – https://www.jaacap.org/article/S0890-8567(09)62592-2/fulltext
- Psychiatric Assessment of Children and Adolescents https://www.jaacap.org/article/S0890-8567(09)62591-0/fulltext
Reminder: It is important that you complete this assessment using your critical thinking skills. You are expected to synthesize 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.”
Submission Instructions:
In addition to the video demonstrating proficiency in completing a comprehensive psychiatric evaluation, students must upload a comprehensive written submission.
- The written submission should be limited to PowerPoint 10-12 slides or a comprehensive psychiatric note and include all sections of the SOAP note listed above.
- The comprehensive psychiatric examination is original work and logically organized, formatted, and cited in the current APA style, including citation of references. 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 wear their lab coats, display their STU or other identification, 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
Grading Rubric
Your assignment will be graded according to the grading rubric.
View Rubric
| Video Case Presentation and Psychiatric SOAP Note Rubric 2022 | ||
| Video Case Presentation and Psychiatric SOAP Note Rubric 2022 | ||
| Criteria | Ratings | Pts |
| Chief Complaint view longer description | 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 view longer description | 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 view longer description | 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 view longer description | 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 view longer description | 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 view longer description | 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 view longer description | 3 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 description | 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 view longer description | 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 |
| Past Psychiatric History-S view longer description | 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 |
| Family Psychiatric History-S view longer description | 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 view longer description | 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 |
| Mental Status Exam-O view longer description | 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 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 >3 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 3 to >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 description | 5 to >3 pts Exemplary Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority) 3 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 | / 5 pts |
| Differential Diagnoses-A view longer description | 3 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 description | 3 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 description | 8 to >6 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. 6 to >4 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. 4 to >2 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. 2 to >0 pts Novice Information is completely missing | / 8 pts |
| Patient/Family Education-P view longer description | 5 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 description | 5 to >3 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. 3 to >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. 2 to >0 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. | / 5 pts |
| APA Formatting view longer description | 5 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 description | 10 pts Exemplary Audio-Video presentation contains 10-15 slides. Well-rehearsed. Voice, eye contact and pacing hold interest and attention of the audience; introduced self and project. 7 pts Distinguished Audio-Video presentation contains a minimum of 10 slides. Fairly fluid delivery. Communicates ideas with proper voice projection; perhaps one mispronounced work; made eye contact 3 pts Developing Audio-Video presentation contains fewer than 10 slides, or some slides designed do not support the therapeutic intervention/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 | / 10 pts |
Requirements:
Hello
So, basically is has to be done in a power point of 10-12 slides where I am supposed to do a comprehensive psychiatric evaluation of an infant or toddler; I would rather do a toddler of 6 years old. Then I will make the video asking the actual questiion to thye child and the parent.
So if you can include the questions it would be great.
Thanks
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