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.

PPT Presentation #1: Infant or Toddler (Under Age 6)

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:

How do I record a Canvas Studio video with a webcam in a course?Links to an external site.

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). Click hereLinks to an external site. for more details

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 GuidelinesLinks to an external site. or APA Clinical GuidelinesLinks to an external site., research articles, and the role of the PMHNP in your presentation.

· Psychiatric Assessment of Infants and ToddlersLinks to an external site.

· Psychiatric Assessment of Children and AdolescentsLinks to an external site.

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.”

· Graduate Mental Status Exam GuideDownload Graduate Mental Status Exam Guide

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).

Psychiatric Pediatric Presentation Rubric
Establishing Rapport – Professionalism	4 to >3 pts Exemplary Introduced self, including (name and role, student PMHNP). 3 to >0 pts Developing Introduced self, including but fails to state role (student PMHNP). 0 pts Novice Does not introduce him/herself (name and role).	/ 4 pts
Establishing Rapport – Professionalism	2 to >1 pts Exemplary Begins interview by identifying patient and caregiver’s by name. 1 to >0 pts Developing Begins interview by identifying patient only. 0 pts Novice Begins interview by identifying caregiver only.	/ 2 pts
Chief Complaint (Reason for seeking health care) – S	4 to >3 pts Exemplary Includes a direct quote from patient about presenting problem. 3 to >0 pts Developing Includes information but information is NOT a direct quote. 0 pts Novice Information is completely missing.	/ 4 pts
History of the Present Illness (HPI) – S	4 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 >0 pts Developing Includes the presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity). 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, and Severity).	/ 4 pts
Review of Systems (ROS) – S	5 to >4 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.” 4 to >0 pts Developing Includes 2 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	3 to >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.) 2 to >0 pts Developing Includes 7 or fewer 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.	/ 3 pts
Labs, Diagnostic Tests and Screening Tools – O	3 to >2 pts Exemplary 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 to >0 pts Developing 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	4 to >3.2 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 of the prescribed medications, herbal or over the counter medications). 3.2 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 prescribed medications, herbal or over the counter medications). 0 pts Novice Information is completely missing.	/ 4 pts
Past Medical History-S	3 to >2 pts Exemplary Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current 2 to >1 pts Distinguished Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current. 1 to >0 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	5 to >4 pts Exemplary Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), and year of diagnosis. 4 to >0 pts Developing Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), and does not include the year of diagnosis. 0 pts Novice Information is completely missing.	/ 5 pts
Family Psychiatric History-S	3 to >2 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 to >0 pts Developing Includes an assessment of at least 3 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	3 to >2 pts Exemplary Includes all 11 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexual activity, developmental history, contraceptive use/pregnancy status, and living situation. 2 to >0 pts Developing Includes 6-10 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexual activity, developmental history, contraceptive use/pregnancy status, and living situation. 0 pts Novice Information is completely missing.	/ 3 pts
Mental Status Exam-O	15 to >12 pts Exemplary Includes greater than 9 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 12 to >0 pts Developing Includes 6-9 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 5 or fewer 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	5 to >4 pts Exemplary Includes a clear outline of the accurate principal diagnosis based on DSM5-TR 4 to >0 pts Developing Includes a medical diagnosis based as the principal diagnosis OR the diagnosis is not a DSM5-TR diagnosis 0 pts Novice Information is completely missing.	/ 5 pts
Differential Diagnoses – A	3 to >2 pts Exemplary Includes at least 2 differential diagnoses for the principal diagnosis based on DSM5-TR 2 to >0 pts Developing Includes 1 differential diagnosis for the principal diagnosis OR the diagnosis is not a DSM5-TR diagnosis 0 pts Novice Information is completely missing.	/ 3 pts
Outcome Labs/Screening Tools – O	3 to >2 pts Exemplary Includes 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 to >0 pts Developing Includes appropriate diagnostic testing less than 50% of the time. 0 pts Novice Information is completely missing.	/ 3 pts
Treatment	6 to >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. 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. 0 pts Novice Information is completely missing.	/ 6 pts
Patient/Family Education – P	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 >0 pts Developing Includes 1-2 strategies to promote and develop skills for managing their illness and at least 1 self-management method on how to incorporate healthy behaviors into their lives. 0 pts Novice Information is completely missing.	/ 5 pts
Professionalism	10 to >5 pts Exemplary The student summarized/concluded the visit at the end of the appointment, asked if there were questions before concluding appointment, demonstrated active listening. The student gave verbal/nonverbal positive reinforcement, and the information was not obtained in a logical, systematic, orderly progression. 5 to >0 pts Developing The student summarized/concluded the visit at the end of the appointment. The student used leading & and why questions and/or medical jargon not actively listen to the patient/parent . The student demonstrated active listening and/or the information was obtained info in logical, systematic, orderly progression. 0 pts Novice The student did not summarize/conclude the visit. The student was unprofessional, did not actively listen. The information was not obtained in a logical manner”	/ 10 pts

Psychiatric Pediatric Presentation Rubric

Criteria

Ratings

Pts

Establishing Rapport – Professionalism

4 to >3 pts

Exemplary

Introduced self, including (name and role, student PMHNP).

3 to >0 pts

Developing

Introduced self, including but fails to state role
(student PMHNP).

0 pts

Novice

Does not introduce him/herself (name and role).

/ 4 pts

Establishing Rapport – Professionalism

2 to >1 pts

Exemplary

Begins interview by identifying patient and caregiver’s by
name.

1 to >0 pts

Developing

Begins interview by identifying patient only.

0 pts

Novice

Begins interview by identifying caregiver only.

/ 2 pts

Chief Complaint (Reason for seeking health care) – S

4 to >3 pts

Exemplary

Includes a direct quote from patient about presenting
problem.

3 to >0 pts

Developing

Includes information but information is NOT a direct quote.

0 pts

Novice

Information is completely missing.

/ 4 pts

History of the Present Illness (HPI) – S

4 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 >0 pts

Developing

Includes the presenting problem and 6 of the 8 dimensions
of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating
factors, Relieving factors, Timing and Severity).

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, and
Severity).

/ 4 pts

Review of Systems (ROS) – S

5 to >4 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.”

4 to >0 pts

Developing

Includes 2 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

3 to >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.)

2 to >0 pts

Developing

Includes 7 or fewer 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.

/ 3 pts

Labs, Diagnostic Tests and Screening Tools – O

3 to >2 pts

Exemplary

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 to >0 pts

Developing

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

4 to >3.2 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 of the prescribed medications, herbal or over the
counter medications).

3.2 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 prescribed medications, herbal or
over the counter medications).

0 pts

Novice

Information is completely missing.

/ 4 pts

Past Medical History-S

3 to >2 pts

Exemplary

Includes (Major/Chronic, Trauma, Hospitalizations), for
each medical diagnosis, year of diagnosis and whether the diagnosis is active
or current

2 to >1 pts

Distinguished

Includes (Major/Chronic, Trauma, Hospitalizations), for
each medical diagnosis, either year of diagnosis OR whether the diagnosis is
active or current.

1 to >0 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

5 to >4 pts

Exemplary

Includes (Outpatient and Hospitalizations), for each
psychiatric diagnosis (including addiction treatment), and year of diagnosis.

4 to >0 pts

Developing

Includes (Outpatient and Hospitalizations), for each
psychiatric diagnosis (including addiction treatment), and does not include
the year of diagnosis.

0 pts

Novice

Information is completely missing.

/ 5 pts

Family Psychiatric History-S

3 to >2 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 to >0 pts

Developing

Includes an assessment of at least 3 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

3 to >2 pts

Exemplary

Includes all 11 of the following: tobacco use, drug use,
alcohol use, marital status, employment status, current and previous
occupation, sexual orientation, sexual activity, developmental history,
contraceptive use/pregnancy status, and living situation.

2 to >0 pts

Developing

Includes 6-10 of the following: tobacco use, drug use,
alcohol use, marital status, employment status, current and previous
occupation, sexual orientation, sexual activity, developmental history,
contraceptive use/pregnancy status, and living situation.

0 pts

Novice

Information is completely missing.

/ 3 pts

Mental Status Exam-O

15 to >12 pts

Exemplary

Includes greater than 9 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

12 to >0 pts

Developing

Includes 6-9 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 5 or fewer 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

5 to >4 pts

Exemplary

Includes a clear outline of the accurate principal
diagnosis based on DSM5-TR

4 to >0 pts

Developing

Includes a medical diagnosis based as the principal diagnosis
OR the diagnosis is not a DSM5-TR diagnosis

0 pts

Novice

Information is completely missing.

/ 5 pts

Differential Diagnoses – A

3 to >2 pts

Exemplary

Includes at least 2 differential diagnoses for the
principal diagnosis based on DSM5-TR

2 to >0 pts

Developing

Includes 1 differential diagnosis for the principal
diagnosis OR the diagnosis is not a DSM5-TR diagnosis

0 pts

Novice

Information is completely missing.

/ 3 pts

Outcome Labs/Screening Tools – O

3 to >2 pts

Exemplary

Includes 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 to >0 pts

Developing

Includes appropriate diagnostic testing less than 50% of
the time.

0 pts

Novice

Information is completely missing.

/ 3 pts

Treatment

6 to >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.

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.

0 pts

Novice

Information is completely missing.

/ 6 pts

Patient/Family Education – P

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 >0 pts

Developing

Includes 1-2 strategies to promote and develop skills for
managing their illness and at least 1 self-management method on how to
incorporate healthy behaviors into their lives.

0 pts

Novice

Information is completely missing.

/ 5 pts

Professionalism

10 to >5 pts

Exemplary

The student summarized/concluded the visit at the end of
the appointment, asked if there were questions before concluding appointment,
demonstrated active listening. The student gave verbal/nonverbal positive
reinforcement, and the information was not obtained in a logical, systematic,
orderly progression.

5 to >0 pts

Developing

The student summarized/concluded the visit at the end of the
appointment. The student used leading & and why questions and/or medical
jargon not actively listen to the patient/parent . The student demonstrated
active listening and/or the information was obtained info in logical,
systematic, orderly progression.

0 pts

Novice

The student did not summarize/conclude the visit. The
student was unprofessional, did not actively listen. The information was not
obtained in a logical manner”

/ 10 pts

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