Nursing Homework
Step 1: For this assignment, students will create a video presentation performing a comprehensive psychiatric evaluation of a school-aged child. You are expected to choose a child and an adult to interview. 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.
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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 information |
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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 |
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A = |
Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes |
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P = |
Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/ family teaching, referral, and follow up |
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Psychiatric Pediatric Presentation Rubric |
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Criteria |
Ratings |
Pts |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 t emperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.) 0 pts Novice Information is completely missing. |
/ 3 pts |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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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Total Points: 0 |
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 Guide Download Graduate Mental Status Exam Guide
Video 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.