Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why?

Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide:
- Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
- Objective: What observations did you make during the psychiatric assessment?
- Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.
- Plan: In your video, describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session?
- In your written plan include all the above as well as include 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.
- Reflection notes: What would you do differently with this patient if you could conduct the session over? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.

PRAC_6665_Week9_Assignment2_Pt1_Rubric

This criterion is linked to a Learning OutcomeDiscuss 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 OutcomeDiscuss 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 OutcomeDiscuss 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 OutcomeDiscuss treatment Plan:• A treatment
plan for the patient that addresses chosen FDA-approved psychopharmacologic
agents and includes alternative treatments available and supported by valid
research. The treatment plan includes rationales, a plan for follow-up
parameters, and referrals. The discussion includes one social determinant of
health according to the HealthyPeople 2030, 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.

20 to >17.0 pts

Excellent

The video clearly and concisely outlines an evidence-based treatment
plan for the patient that addresses FDA-approved psychopharmacologic agents
and includes alternative treatments and rationale supported by valid
research. … Discussion includes a clear and concise follow-up plan and
parameters…. The discussion includes a clear and concise referral plan.
… The paper discussion contains all 3 elements from the assignment
directions including a discussion demonstrating critical thinking of the
case related to the HealthyPeople 2030 social health determinates. Clearly
and concisely relates discussion to the psychiatric and mental health
field.

17 to >15.0 pts

Good

The video clearly outlines an appropriate treatment plan without
evidence-based discussion for the patient that addresses FDA-approved
psychopharmacologic agents and includes alternative treatments and
rationale supported by vague or questionable research. … Discussion
includes a clear follow-up plan and parameters…. The discussion includes
a clear referral plan…. The paper discussion contains 2 of the elements
from the assignment directions with one being a basic discussion of the
case related to the HealthyPeople 2030 social health determinates. Clearly
relates discussion to the psychiatric and mental health field.

15 to >13.0 pts

Fair

The response somewhat vaguely or inaccurately outlines a treatment
plan for the patient that addresses psychopharmacologic agents without
discussion of FDA approval and includes vague or inaccurate alternative
treatments with little rationale discussed. … 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. …
The paper discussion contains 1 of the required elements from the
assignment directions which is the HealthyPeople 2030 social health
determinates…. Somewhat vaguely or inaccurately relates discussion to the
psychiatric and mental health field.

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. There is no
mention of FDA approval for treatment choices or no research supported
discussion. Alternative treatment discussion is missing. … Rationales for
treatments are missing. … There is no discussion for follow-up and
parameters. … There is no discussion of a referral plan. … The paper
discussion is missing discussion relating to the psychiatric and mental
health field or relates discussion to another specialty realm including
medical co-morbidity illnesses.

20 pts

This criterion is linked to a Learning OutcomeReflect on this case. Discuss what
you learned and what you might do differently.

5 to >4.0 pts

Excellent

Reflections are thorough, thoughtful, and demonstrate critical
thinking.

4 to >3.5 pts

Good

Reflections demonstrate critical thinking.

3.5 to >3.0 pts

Fair

Reflections are somewhat general or do not demonstrate critical
thinking.

3 to >0 pts

Poor

Reflections are incomplete, inaccurate, or missing.

5 pts

This criterion is linked to a Learning OutcomePresentation 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 >3.0 pts

Fair

Presentation style is mostly clear, professional, and focused

3 to >0 pts

Poor

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

5 pts

Total
Points: 80

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