You will create a PowerPoint presentation with a realistic case study and include appropriate and pertinent clinical information
You will create a PowerPoint presentation with a realistic case study and include appropriate and pertinent clinical information
For this assignment, you will develop a realistic clinical case presentation. Use PowerPoint to create the slides for your presentation. Content Requirements
You will create a PowerPoint presentation with a realistic case study and include appropriate and pertinent clinical information based on the DSM5-TR and current US clinical guidelines to support the case:
- Subjective data:
- Chief Complaint
- Demographics
- History of the Present Illness (HPI) includes the presenting problem and the 8 dimensions of the problem. See an example of the correct way to document the psychiatric HPI hereLinks to an external site. – https://www.aapc.com/blog/25848-successfully-capture-hpi-elements-in-psychiatry-em-notes/#:~:text=The%20history%20of%20present%20illness,and%20associated%20signs%20and%20symptoms.
- Review of Systems (ROS)
- Objective data:
- Current Medications
- Allergies
- Past medical history
- Family psychiatric history
- Past surgical history
- Social history
- Labs and screening tools
- Vital signs
- Physical exam
- Assessment:
- Primary Diagnosis – DSM5 only
- Differential diagnosis – DSM5 only
- Plan:
- Pharmacologic treatment plan
- Non-pharmacologic treatment plan
- Follow up plan
- Other:
- Incorporation of current US clinical guidelines
- Integration of research articles
- Role of the nurse practitioner
Requirements: 15 slides
Masters Nursing
Submission Instructions:
- The presentation is original work and logically organized, formatted, and cited in the current APA style, including citation of references. speaker notes, will be evaluated for this assignment.
- The presentation should consist of 10-15 slides.
- Incorporate a minimum of 4 current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work. Journal articles should be referenced according to the current APA style (the online library has an abbreviated version of the APA Manual).
1 day ago
Grading Rubric
Your assignment will be graded according to the grading rubric.
| Realistic Case Presentation Rubric | |||||
| Criteria | Ratings | Points | |||
| Chief Complaint (Reason for seeking health care) – S | Exemplary – 4 points Includes a direct quote from the patient about presenting problem. | Distinguished – 3 points Includes a direct quote from the patient and other unrelated information. | Developing – 1-2 points Includes information but the information is NOT a direct quote. | Novice – 0 points Information is completely missing. | 4 points |
| Demographics – S | Exemplary – 2 points Begins with patient initials, age, race, ethnicity, and gender (5 demographics). | Distinguished – 1.5 points Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity, and gender). | Developing – 1 point Begins with 3 or less patient demographics (patient initials, age, race, ethnicity, and gender). | Novice – 0 points Information is completely missing. | 2 points |
| History of the Present Illness (HPI) – S | Exemplary – 4-5 points Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity). | Distinguished – 3 points Includes the presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing. | Developing – 2 points Includes the presenting problem and 4 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing. | Novice – 0-1 point 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 points |
| Allergies – S | Exemplary – 2 points 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). | Distinguished – 1.5 points Only screened for one type of allergy (drug, environmental, herbal, food or latex). If allergies are present, list type drug, environmental factor, herbal, food, latex name and include the severity of allergy OR description of the allergy. | Developing – 1 points If allergies are present, students lists only the type of allergy name. | Novice – 0 points Information is completely missing. | 2 points |
| Review of Systems (ROS) – S | Exemplary – 4-5 points 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”. | Distinguished – 3 points 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”. | Developing – 1-2 points 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”. | Novice – 0 points Information is completely missing. | 5 points |
| Vital Signs – O | Exemplary – 2 points 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.). | Distinguished – 1.5 points 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.). | Developing – 1 point 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.). | Novice – 0 points Information is completely missing. | 2 points |
| Labs, Diagnostic Tests and Screening Tools – O | Exemplary – 3 points Includes a list of the labs, diagnostic tests, or screening tools that should be completed for identified patient that are based on the US clinical guidelines OR acknowledges no labs/diagnostic tests are recommended. | Distinguished – 2 points Includes a list of the labs, diagnostic tests, or screening tools that should be completed the identified patient but they do not follow the US clinical guidelines. | Developing – 1 point Includes a list of the labs, diagnostic tests, or screening tools reviewed for the identified patient but they are inappropriate or do not address the patient’s problem. | Novice – 0 points Information is completely missing. | 3 points |
| Medications-S | Exemplary – 4 points Includes a list of all of the patient reported psychiatric and medical medications and the diagnosis for the medication (including name, dose, route, frequency). | Distinguished – 3 points 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). | Developing – 1-2 points 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). | Novice – 0 point Information is completely missing. | 4 points |
| Past Medical History-S | Exemplary – 3 points Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current. | Distinguished – 2 points Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current. | Developing – 1 point Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current. | Novice – 0 points Information is completely missing. | 3 points |
| Past Psychiatric History-S | Exemplary – 4-5 points Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), year of diagnosis and. | Distinguished – 3 points Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (omits addiction treatment), year of diagnosis. | Developing – 1-2 points Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), does not include the year of diagnosis. | Novice – 0 points Information is completely missing. | 5 points |
| Family Psychiatric History-S | Exemplary – 3 points Includes an assessment of at least 6 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder and history of suicidal attempts. | Distinguished – 2 points Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder and history of suicidal attempts. | Developing – 1 point Includes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder and history of suicidal attempts. | Novice – 0 points Information is completely missing. | 3 points |
| Social History-S | Exemplary – 3 points 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. | Distinguished – 2 points 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. | Developing – 1 point 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. | Novice – 0 points Information is completely missing. | 3 points |
| Mental Status Exam-O | Exemplary – 12-15 points 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. | Distinguished – 8-11 points 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. | Developing – 4-7 points 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. | Novice – 0-3 points 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 points |
| Primary Diagnoses-A | Exemplary – 5-6 points Includes a clear outline of the accurate principal diagnosis based on DSM5 or DSM5-TR criteria. | Distinguished – 3-4 points Includes an inaccurate diagnosis as the principal diagnosis based on DSM5 or DSM5-TR criteria. | Developing – 1-2 point Includes a medical diagnosis based as the principal diagnosis OR the diagnosis is not a DSM5 or DSM5-TR diagnosis. | Novice – 0 points Information is completely missing. | 6 points |
| Differential Diagnoses-A | Exemplary – 3 points Includes at least 2 differential diagnoses for the principal diagnosis. | Distinguished – 2 points Includes 2 differential diagnoses for the principal diagnosis. | Developing – 1 point Includes 1 differential diagnosis for the principal diagnosis. | Novice – 0 points Information is completely missing. | 3 points |
| Treatment | Exemplary – 11-15 points 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. | Distinguished – 6-10 points 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. | Developing – 1-5 points 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. | Novice – 0 point Information is completely missing. | 15 points |
| Referral | Exemplary – 4-5 points 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. | Distinguished – 3 points Provides a medical or other interdisciplinary referral or documents NO REFERRAL ADVISED AT THIS TIME. Includes a timeline for follow up appointments. | Developing – 1-2 points Provides a medical or other interdisciplinary referral. DOES NOT include a timeline for follow up appointments. | Novice – 0 points Information is completely missing. | 5 points |
| APA Formatting | Exemplary – 4-5 points 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. | Distinguished – 3 points 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. | Developing – 1-2 points 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. | Novice – 0 points APA style and writing mechanics not used. | 5 points |
| Total Points | 90 | ||||
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