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Select a patient for whom you conducted psychotherapy for an impulse control or conduct disorderduring the last 6 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in

·        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 disorderduring 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 by your Preceptor. When you submit your note, you should include the complete comprehensive evaluation note as a Word document and pdf/images of the completed assignment signed by your Preceptor. You must submit your note using Turnitin.
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 for your clinical patient.

Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video. 

In your presentation:

·        Dress professionally 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: 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-TR diagnostic criteria and is supported by the patient’s symptoms. 

o   Plan: Describe your treatment modality and your plan for psychotherapy. Explain the principles of psychotherapy that underline your chosen treatment plan to support your rationale for the chosen psychotherapy framework. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this psychotherapy session?

o   Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.

submission information – Part 1: Recording

To submit your video response entry:

Click on Start Assignment near the top of the page.Next, click Text Entry and then click the Embed Kaltura Media button.Select your recorded video under My Media.Check the box for the End-User License Agreement and select Submit Assignment for review.

submission information – Part 2: Comprehensive Psychiatric Evaluation Note

To submit Part 2 of this Assignment, click on the following link:

·        Week 7 Assignment 2, Part 2

Rubric

PRAC_6645_Week7_Assignment2_PT1_Rubric

PRAC_6645_Week7_Assignment2_PT1_Rubric

Criteria

Ratings

Pts

This
criterion is linked to a Learning Outcome
Photo ID
display and professional attire

5 to >0.0 pts

Excellent

Photo ID is displayed. The
student is dressed professionally.

0 pts

Fair

0 pts

Good

0 pts

Poor

Photo ID is not displayed.
Student must remedy this before grade is posted. The student is not dressed
professionally.

5 pts

This
criterion is linked to a Learning Outcome
Time

5 to >3.0 pts

Excellent

The video does not exceed the
8-minute time limit.

3 to >0.0 pts

Good

The video exceeds the 8-minute time
limit. (Note: Information presented after 8 minutes will not be evaluated
for grade inclusion.)

0 pts

Fair

0 pts

Poor

5 pts

This
criterion is linked to a Learning Outcome
Discuss
Subjective data:• Chief complaint• History of present illness (HPI)•
Medications• Psychotherapy or previous psychiatric diagnosis• Pertinent
histories and/or ROS

10 to >8.0 pts

Excellent

The video accurately and
concisely presents the patient’s subjective complaint, history of present
illness, medications, psychotherapy or previous psychiatric diagnosis, and
pertinent histories and/or review of systems that would inform a
differential diagnosis.

8 to >7.0 pts

Good

The video accurately presents
the patient’s subjective complaint, history of present illness,
medications, psychotherapy or previous psychiatric diagnosis, and pertinent
histories and/or review of systems that would inform a differential
diagnosis.

7 to >6.0 pts

Fair

The video presents the patient’s
subjective complaint, history of present illness, medications,
psychotherapy or previous psychiatric diagnosis, and pertinent histories
and/or review of systems that would inform a differential diagnosis, but is
somewhat vague or contains minor inaccuracies.

6 to >0 pts

Poor

The video presents an
incomplete, inaccurate, or unnecessarily detailed/verbose description of
the patient’s subjective complaint, history of present illness,
medications, psychotherapy or previous psychiatric diagnosis, and pertinent
histories and/or review of systems that would inform a differential
diagnosis. Or subjective documentation is missing.

10 pts

This
criterion is linked to a Learning Outcome
Discuss
Objective data:• Physical exam documentation of systems pertinent to the
chief complaint, HPI, and history• Diagnostic results, including any labs,
imaging, or other assessments needed to develop the differential diagnoses

10 to >8.0 pts

Excellent

The video accurately and
concisely documents the patient’s physical exam for pertinent systems.
Pertinent diagnostic tests and their results are documented, as applicable.

8 to >7.0 pts

Good

The response accurately
documents the patient’s physical exam for pertinent systems. Diagnostic
tests and their results are documented, as applicable.

7 to >6.0 pts

Fair

Documentation of the patient’s
physical exam is somewhat vague or contains minor inaccuracies. Diagnostic
tests and their results are documented but contain inaccuracies.

6 to >0 pts

Poor

The response provides
incomplete, inaccurate, or unnecessarily detailed/verbose documentation of
the patient’s physical exam. Systems may have been unnecessarily reviewed,
or objective documentation is missing.

10 pts

This
criterion is linked to a Learning Outcome
Discuss
results of Assessment:• Results of the mental status examination• 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.

20 to >17.0 pts

Excellent

The video accurately documents
the results of the mental status exam…. Video presents at least three
differentials in order of priority for a differential diagnosis of the
patient, and a rationale for their selection. Response justifies the
primary diagnosis and how it aligns with DSM-5 criteria.

17 to >15.0 pts

Good

The video adequately documents
the results of the mental status exam…. Video presents three
differentials for the patient and a rationale for their selection. Response
adequately justifies the primary diagnosis and how it aligns with DSM-5
criteria.

15 to >13.0 pts

Fair

The video presents the results
of the mental status exam, with some vagueness or inaccuracy…. Video
presents three differentials for the patient and a rationale for their
selection. Response somewhat vaguely justifies the primary diagnosis and
how it aligns with DSM-5 criteria.

13 to >0 pts

Poor

The response provides an
incomplete, inaccurate, or unnecessarily detailed/verbose description of
the results of the mental status exam and explanation of the differential
diagnoses. Or assessment documentation is missing.

20 pts

This
criterion is linked to a Learning Outcome
Discuss
treatment Plan:• A treatment plan for the patient that addresses
psychotherapy and rationales including a plan for follow-up parameters and
referrals

20 to >17.0 pts

Excellent

The video clearly and concisely
outlines an evidence-based treatment plan for the patient that addresses
treatment modality, psychotherapy choice with framework principles, and
rationale. … Discussion includes a clear and concise follow-up plan and
parameters…. The discussion includes a clear and concise referral plan.

17 to >15.0 pts

Good

The video clearly outlines an
appropriate treatment plan without evidence-based discussion for the
patient that addresses treatment modality, psychotherapy choice with framework
principles, and rationale. … Discussion includes a clear follow-up plan
and parameters…. The discussion includes a clear referral plan.

15 to >13.0 pts

Fair

The response somewhat vaguely or
inaccurately outlines a treatment plan for the patient and provides a
rationale for the treatment approaches recommended…. The discussion is
somewhat vague or inaccurate regarding the follow-up plan and
parameters…. The discussion is somewhat vague or inaccurate regarding a
referral plan.

13 to >0 pts

Poor

The response does not address
the treatment plan or the treatment plan is not appropriate for the
assessment and the diagnosis or is missing elements of the treatment plan.
… There is no discussion for follow-up and parameters. … There is no
discussion of a referral plan.

20 pts

This
criterion is linked to a Learning Outcome
Presentation
style

5 to >4.0 pts

Excellent

Presentation style is
exceptionally clear, professional, and focused.

4 to >3.5 pts

Good

Presentation style is clear,
professional, and focused.

3.5 to >2.0 pts

Fair

Presentation style is mostly
clear, professional, and focused.

2 to >0 pts

Poor

Presentation style is unclear,
unprofessional, and/or unfocused.

5 pts

Total Points: 75

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