CF- Treatment Plan
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CaseFormulationandTreatmentPlan_PaperRubric.pdf
C.F-TREATMENTPLAN.docx
CaseFormulationandTreatmentPlan_PaperRubric.pdf
Grading Rubric for Written Assignments Course: NSG-526-IKB - Clin Modal Adv. Psy/MH NP
Criteria Unacceptable Acceptable Good Excellent Criterion Score
Introduction / 15
Focus and
Sequencing
/ 20
0 points
Does not ade-
quately convey
topic. Does not de-
lineate subtopics to
be discussed in the
body of text in the
assignment.
5 points
Briefly conveys
topic and delineates
subtopics to be dis-
cussed in the body
of text in the
assignment.
10 points
Clearly conveys
topic and delineates
subtopics to be dis-
cussed in the body
of text in the
assignment.
15 points
Strongly conveys
topic and delineates
subtopics to be dis-
cussed in the body
of text in the
assignment.
0 points
Content is not re-
lated to topic and
logically organized
into subtopics; many
transitions are un-
clear or nonexistent.
8 points
Content related to
topic; material
present within
subtopics; and some
transitions linking
subtopics and main
topic.
14 points
Content clearly re-
lated to topic; logi-
cally organized
within subtopics;
and clear transitions
linking subtopics
and main topic.
20 points
Content strongly re-
lated to topic;
strong organization
and integration of
content within
subtopics; and
strong transitions
linking subtopics
and main topic.
10/26/26, 3:17 PM Case Formulation and Treatment Plan/Paper - NSG-526-IKB - Clin Modal Adv. Psy/MH NP - L.I.V.E. - Wilkes University
https://live.wilkes.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=710798&grpid=0&isprv=0&bp=0&ou=388072 1/3
Criteria Unacceptable Acceptable Good Excellent Criterion Score
Support / 20
Conclusion / 15
Grammar,
Spelling and
Punctuation
/ 10
0 points
No scholarly, peer-
reviewed support of
topic; supporting
materials are not
published within 5-7
years, as
appropriate.
8 points
Limited scholarly,
peer-reviewed sup-
port of topic; most
supporting materials
are published within
5-7 years, as
appropriate.
14 points
Clear scholarly,
peer-reviewed sup-
port of topic; sup-
porting materials are
published within 5-7
years, as
appropriate.
20 points
Strong scholarly,
peer-reviewed sup-
port of topic; sup-
porting materials are
published within 5-7
years, as
appropriate.
0 points
No summarization,
synthesis, or insight-
ful discussion of
topic conclusions.
New information is
introduced into the
conclusion.
5 points
Summarization with
some synthesis and
insightful discussion
of topic conclusions.
Some new informa-
tion is introduced
into the conclusion.
10 points
Clear summarization
with synthesis and
insightful discussion
of topic conclusions.
No new information
is introduced into
the conclusion.
15 points
Strong summariza-
tion with synthesis
and insightful dis-
cussion of topic
conclusions. No new
information is intro-
duced into the con-
clusion.
0 points
Substantial gram-
mar, spelling, and
punctuation errors
detracting from the
assignment.
3 points
Occasional spelling,
grammar, and punc-
tuation errors de-
tracting from the
assignment.
7 points
Minimal grammar,
spelling, and punc-
tuation errors not
detracting from the
assignment.
10 points
No grammar, spell-
ing, and punctuation
errors.
10/26/26, 3:17 PM Case Formulation and Treatment Plan/Paper - NSG-526-IKB - Clin Modal Adv. Psy/MH NP - L.I.V.E. - Wilkes University
https://live.wilkes.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=710798&grpid=0&isprv=0&bp=0&ou=388072 2/3
Total / 100
Overall Score
Criteria Unacceptable Acceptable Good Excellent Criterion Score
Writing
Mechanics
/ 10
APA Style / 10
0 points
Writing mechanics
include many awk-
ward or unclear pas-
sages and informal
tone not consistent
with formal schol-
arly work.
3 points
Writing mechanics
include awkward or
unclear passages
and informal tone
not always consis-
tent with formal
scholarly work.
7 points
Writing mechanics
include minimal
awkward or unclear
passages but are
consistent with for-
mal scholarly work.
10 points
Writing mechanics
are consistent with
formal scholarly
work.
0 points
Substantial errors in
APA style based
upon the required
APA manuals listed
on the course
syllabi.
3 points
Occasional errors in
APA style based
upon the required
APA manuals listed
on the course
syllabi.
7 points
Minimal errors in
APA style based
upon the required
APA manuals listed
on the course
syllabi.
10 points
No errors in APA
style based upon
the required APA
manuals listed on
the course syllabi.
Level 1 0 points minimum
Level 2 7 points minimum
Level 3 11 points minimum
Level 4 15 points minimum
10/26/26, 3:17 PM Case Formulation and Treatment Plan/Paper - NSG-526-IKB - Clin Modal Adv. Psy/MH NP - L.I.V.E. - Wilkes University
https://live.wilkes.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=710798&grpid=0&isprv=0&bp=0&ou=388072 3/3
C.F-TREATMENTPLAN.docx
SOAP 1:
Demographics: 37-year-old female, divorced, employed part-time, lives with her two children.
Visit Type: 60-minute initial psychiatric evaluation via secure telemedicine.
Reason for Visit: Evaluation of trauma-related symptoms, worsening depression, and sleep disturbances.
Chief Complaint: “I keep reliving things that happened to me when I was younger. I'm depressed, exhausted, and can't sleep.”
Psychiatric Diagnoses:
· Post-traumatic stress disorder (F43.10)
· Major depressive disorder, recurrent, moderate (F33.1)
Medical Comorbidities: Asthma and GERD.
Current Medications: Albuterol inhaler PRN and Omeprazole 20 mg daily. No current psychiatric medications.
Social Problems: Childhood trauma, history of abusive relationships, financial stress, single parenting, and limited social support.
Procedures: Comprehensive psychiatric evaluation, MSE, trauma history assessment, PTSD and depression screening, sleep assessment, medication reconciliation, substance-use screening, and suicide risk assessment.
Clinical Note: Patient reports intrusive memories, recurrent nightmares, hypervigilance, exaggerated startle response, and avoidance behaviors related to childhood physical abuse. Also endorses depressed mood, anhedonia, fatigue, feelings of worthlessness, and difficulty concentrating for the past four months. Reports sleeping approximately 4–5 hours nightly. Denies mania, psychosis, substance misuse, SI, or HI.
S (Subjective): Reports persistent sadness, nightmares, flashbacks, poor sleep, low motivation, and social withdrawal. States symptoms interfere with parenting and occupational functioning.
O (Objective): Alert and oriented ×4, appropriately groomed, cooperative. Mood depressed; affect constricted. Speech normal, thought process linear. No psychosis or SI/HI. Insight and judgment fair.
A (Assessment): PTSD with persistent trauma-related symptoms and comorbid recurrent moderate MDD. Significant psychosocial stressors contribute to impaired functioning. No acute psychiatric safety concerns identified.
P (Plan): Start sertraline 25 mg PO daily for 7 days, then increase to 50 mg daily if tolerated. Discuss medication risks, benefits, and potential side effects. Recommend trauma-focused CBT or EMDR, sleep hygiene, and supportive counseling. Review safety plan and crisis resources. Monitor mood, PTSD symptoms, and medication tolerability. Follow up in 2 weeks.
New Medication: Sertraline 25 mg PO daily × 7 days, then 50 mg daily as tolerated.
Activity Time: 60 minutes Complexity: Moderate CPT: 90792 ICD-10-CM: F43.10, F33.1
SOAP 2 :
Demographics: 45-year-old male, divorced, employed part-time, lives with his sister.
Visit Type: 60-minute initial psychiatric evaluation via secure telemedicine.
Reason for Visit: Evaluation of mood instability, irritability, impulsive behavior, and worsening depressive symptoms.
Chief Complaint: “My mood is all over the place. Sometimes I feel unstoppable, and then I crash and don't want to do anything.”
Psychiatric Diagnoses:
· Bipolar I disorder, current episode depressed, moderate (F31.32)
· Generalized anxiety disorder (F41.1)
Medical Comorbidities: Hypertension, hyperlipidemia, and obstructive sleep apnea.
Current Medications: Amlodipine 5 mg daily, Atorvastatin 20 mg nightly. No current psychiatric medications.
Social Problems: Recent divorce, financial difficulties, unstable employment, strained family relationships, and limited social support.
Procedures: Comprehensive psychiatric evaluation, MSE, mood disorder assessment, mania/depression screening, medication reconciliation, sleep assessment, substance-use screening, and suicide risk assessment.
Clinical Note: Patient reports depressed mood, anhedonia, fatigue, irritability, poor concentration, and decreased motivation for the past two months. Describes previous manic episodes lasting over one week, characterized by decreased need for sleep, excessive energy, pressured speech, grandiosity, and impulsive spending resulting in significant financial consequences. Denies current mania, psychosis, SI, or HI. Reports no recent substance misuse.
S (Subjective): Reports persistent depression, low motivation, excessive worry, disrupted sleep, and difficulty managing daily responsibilities. History of distinct manic episodes with significant functional impairment.
O (Objective): Alert and oriented ×4, casually dressed, cooperative. Mood depressed; affect constricted. Speech normal, thought process linear. No overt psychosis or SI/HI. Insight and judgment fair.
A (Assessment): Bipolar I disorder, current depressive episode, moderate, with comorbid GAD. History of mania and ongoing functional impairment. No acute psychiatric safety concerns identified.
P (Plan): Initiate lurasidone 20 mg PO daily with at least 350 calories of food. Review risks, benefits, and potential adverse effects, including akathisia, EPS, and metabolic changes. Obtain baseline weight, BMI, BP, HbA1c, and lipid panel. Recommend psychotherapy, mood tracking, consistent sleep schedule, and sleep apnea treatment adherence. Monitor mood stability, medication tolerability, and safety. Follow up in 2 weeks.
New Medication: Lurasidone 20 mg PO daily with food.
Activity Time: 60 minutes Complexity: Moderate CPT: 90792 ICD-10-CM: F31.32, F41.1
Case Formulation and Treatment Plan Assignment
Purpose: The purpose of this assignment is to complete a comprehensive treatment plan for a specific client (i.e., a client in your clinical practicum, a client in your place of employment, a family member or friend). Assessment, diagnosis, and treatment planning are components of the course and sections to be addressed in this assignment. You cannot use the same case used in another course.
Assignment: The student will be required to provide a DSM-5 TR diagnosis, a treatment plan and a summary integrating evidence-based literature and justifying the treatment plan the student developed for the client. The student will also cross-reference the diagnosis with the DSM 5 TR and note all patient symptoms matching criteria. Submit this assignment to the DROPBOX at the end of Unit 10.
|
Subheadings |
|
|
· Identifying information such as demographic information – age, gender, ethnicity, education (DO NOT USE FULL NAMES) · Presenting problem · Mental status description · Medical problems |
This is equal to the Introduction on the Grading Rubric |
|
· DSM 5 TR differential diagnoses with codes · Detailed treatment plan with rationale. Include · medications (psychotropic medications only). · DSM 5 TR Diagnosis compare patient symptoms with diagnostic criteria |
This is equal to the Focus & Sequencing on the Grading Rubric |
|
· Client’s strengths · Goals · Expected outcomes |
This is equal to the Conclusion on the Grading Rubric |
CaseFormulationandTreatmentPlan_PaperRubric.pdf
Grading Rubric for Written Assignments Course: NSG-526-IKB - Clin Modal Adv. Psy/MH NP
Criteria Unacceptable Acceptable Good Excellent Criterion Score
Introduction / 15
Focus and
Sequencing
/ 20
0 points
Does not ade-
quately convey
topic. Does not de-
lineate subtopics to
be discussed in the
body of text in the
assignment.
5 points
Briefly conveys
topic and delineates
subtopics to be dis-
cussed in the body
of text in the
assignment.
10 points
Clearly conveys
topic and delineates
subtopics to be dis-
cussed in the body
of text in the
assignment.
15 points
Strongly conveys
topic and delineates
subtopics to be dis-
cussed in the body
of text in the
assignment.
0 points
Content is not re-
lated to topic and
logically organized
into subtopics; many
transitions are un-
clear or nonexistent.
8 points
Content related to
topic; material
present within
subtopics; and some
transitions linking
subtopics and main
topic.
14 points
Content clearly re-
lated to topic; logi-
cally organized
within subtopics;
and clear transitions
linking subtopics
and main topic.
20 points
Content strongly re-
lated to topic;
strong organization
and integration of
content within
subtopics; and
strong transitions
linking subtopics
and main topic.
10/26/26, 3:17 PM Case Formulation and Treatment Plan/Paper - NSG-526-IKB - Clin Modal Adv. Psy/MH NP - L.I.V.E. - Wilkes University
https://live.wilkes.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=710798&grpid=0&isprv=0&bp=0&ou=388072 1/3
Criteria Unacceptable Acceptable Good Excellent Criterion Score
Support / 20
Conclusion / 15
Grammar,
Spelling and
Punctuation
/ 10
0 points
No scholarly, peer-
reviewed support of
topic; supporting
materials are not
published within 5-7
years, as
appropriate.
8 points
Limited scholarly,
peer-reviewed sup-
port of topic; most
supporting materials
are published within
5-7 years, as
appropriate.
14 points
Clear scholarly,
peer-reviewed sup-
port of topic; sup-
porting materials are
published within 5-7
years, as
appropriate.
20 points
Strong scholarly,
peer-reviewed sup-
port of topic; sup-
porting materials are
published within 5-7
years, as
appropriate.
0 points
No summarization,
synthesis, or insight-
ful discussion of
topic conclusions.
New information is
introduced into the
conclusion.
5 points
Summarization with
some synthesis and
insightful discussion
of topic conclusions.
Some new informa-
tion is introduced
into the conclusion.
10 points
Clear summarization
with synthesis and
insightful discussion
of topic conclusions.
No new information
is introduced into
the conclusion.
15 points
Strong summariza-
tion with synthesis
and insightful dis-
cussion of topic
conclusions. No new
information is intro-
duced into the con-
clusion.
0 points
Substantial gram-
mar, spelling, and
punctuation errors
detracting from the
assignment.
3 points
Occasional spelling,
grammar, and punc-
tuation errors de-
tracting from the
assignment.
7 points
Minimal grammar,
spelling, and punc-
tuation errors not
detracting from the
assignment.
10 points
No grammar, spell-
ing, and punctuation
errors.
10/26/26, 3:17 PM Case Formulation and Treatment Plan/Paper - NSG-526-IKB - Clin Modal Adv. Psy/MH NP - L.I.V.E. - Wilkes University
https://live.wilkes.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=710798&grpid=0&isprv=0&bp=0&ou=388072 2/3
Total / 100
Overall Score
Criteria Unacceptable Acceptable Good Excellent Criterion Score
Writing
Mechanics
/ 10
APA Style / 10
0 points
Writing mechanics
include many awk-
ward or unclear pas-
sages and informal
tone not consistent
with formal schol-
arly work.
3 points
Writing mechanics
include awkward or
unclear passages
and informal tone
not always consis-
tent with formal
scholarly work.
7 points
Writing mechanics
include minimal
awkward or unclear
passages but are
consistent with for-
mal scholarly work.
10 points
Writing mechanics
are consistent with
formal scholarly
work.
0 points
Substantial errors in
APA style based
upon the required
APA manuals listed
on the course
syllabi.
3 points
Occasional errors in
APA style based
upon the required
APA manuals listed
on the course
syllabi.
7 points
Minimal errors in
APA style based
upon the required
APA manuals listed
on the course
syllabi.
10 points
No errors in APA
style based upon
the required APA
manuals listed on
the course syllabi.
Level 1 0 points minimum
Level 2 7 points minimum
Level 3 11 points minimum
Level 4 15 points minimum
10/26/26, 3:17 PM Case Formulation and Treatment Plan/Paper - NSG-526-IKB - Clin Modal Adv. Psy/MH NP - L.I.V.E. - Wilkes University
https://live.wilkes.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=710798&grpid=0&isprv=0&bp=0&ou=388072 3/3
C.F-TREATMENTPLAN.docx
SOAP 1:
Demographics: 37-year-old female, divorced, employed part-time, lives with her two children.
Visit Type: 60-minute initial psychiatric evaluation via secure telemedicine.
Reason for Visit: Evaluation of trauma-related symptoms, worsening depression, and sleep disturbances.
Chief Complaint: “I keep reliving things that happened to me when I was younger. I'm depressed, exhausted, and can't sleep.”
Psychiatric Diagnoses:
· Post-traumatic stress disorder (F43.10)
· Major depressive disorder, recurrent, moderate (F33.1)
Medical Comorbidities: Asthma and GERD.
Current Medications: Albuterol inhaler PRN and Omeprazole 20 mg daily. No current psychiatric medications.
Social Problems: Childhood trauma, history of abusive relationships, financial stress, single parenting, and limited social support.
Procedures: Comprehensive psychiatric evaluation, MSE, trauma history assessment, PTSD and depression screening, sleep assessment, medication reconciliation, substance-use screening, and suicide risk assessment.
Clinical Note: Patient reports intrusive memories, recurrent nightmares, hypervigilance, exaggerated startle response, and avoidance behaviors related to childhood physical abuse. Also endorses depressed mood, anhedonia, fatigue, feelings of worthlessness, and difficulty concentrating for the past four months. Reports sleeping approximately 4–5 hours nightly. Denies mania, psychosis, substance misuse, SI, or HI.
S (Subjective): Reports persistent sadness, nightmares, flashbacks, poor sleep, low motivation, and social withdrawal. States symptoms interfere with parenting and occupational functioning.
O (Objective): Alert and oriented ×4, appropriately groomed, cooperative. Mood depressed; affect constricted. Speech normal, thought process linear. No psychosis or SI/HI. Insight and judgment fair.
A (Assessment): PTSD with persistent trauma-related symptoms and comorbid recurrent moderate MDD. Significant psychosocial stressors contribute to impaired functioning. No acute psychiatric safety concerns identified.
P (Plan): Start sertraline 25 mg PO daily for 7 days, then increase to 50 mg daily if tolerated. Discuss medication risks, benefits, and potential side effects. Recommend trauma-focused CBT or EMDR, sleep hygiene, and supportive counseling. Review safety plan and crisis resources. Monitor mood, PTSD symptoms, and medication tolerability. Follow up in 2 weeks.
New Medication: Sertraline 25 mg PO daily × 7 days, then 50 mg daily as tolerated.
Activity Time: 60 minutes Complexity: Moderate CPT: 90792 ICD-10-CM: F43.10, F33.1
SOAP 2 :
Demographics: 45-year-old male, divorced, employed part-time, lives with his sister.
Visit Type: 60-minute initial psychiatric evaluation via secure telemedicine.
Reason for Visit: Evaluation of mood instability, irritability, impulsive behavior, and worsening depressive symptoms.
Chief Complaint: “My mood is all over the place. Sometimes I feel unstoppable, and then I crash and don't want to do anything.”
Psychiatric Diagnoses:
· Bipolar I disorder, current episode depressed, moderate (F31.32)
· Generalized anxiety disorder (F41.1)
Medical Comorbidities: Hypertension, hyperlipidemia, and obstructive sleep apnea.
Current Medications: Amlodipine 5 mg daily, Atorvastatin 20 mg nightly. No current psychiatric medications.
Social Problems: Recent divorce, financial difficulties, unstable employment, strained family relationships, and limited social support.
Procedures: Comprehensive psychiatric evaluation, MSE, mood disorder assessment, mania/depression screening, medication reconciliation, sleep assessment, substance-use screening, and suicide risk assessment.
Clinical Note: Patient reports depressed mood, anhedonia, fatigue, irritability, poor concentration, and decreased motivation for the past two months. Describes previous manic episodes lasting over one week, characterized by decreased need for sleep, excessive energy, pressured speech, grandiosity, and impulsive spending resulting in significant financial consequences. Denies current mania, psychosis, SI, or HI. Reports no recent substance misuse.
S (Subjective): Reports persistent depression, low motivation, excessive worry, disrupted sleep, and difficulty managing daily responsibilities. History of distinct manic episodes with significant functional impairment.
O (Objective): Alert and oriented ×4, casually dressed, cooperative. Mood depressed; affect constricted. Speech normal, thought process linear. No overt psychosis or SI/HI. Insight and judgment fair.
A (Assessment): Bipolar I disorder, current depressive episode, moderate, with comorbid GAD. History of mania and ongoing functional impairment. No acute psychiatric safety concerns identified.
P (Plan): Initiate lurasidone 20 mg PO daily with at least 350 calories of food. Review risks, benefits, and potential adverse effects, including akathisia, EPS, and metabolic changes. Obtain baseline weight, BMI, BP, HbA1c, and lipid panel. Recommend psychotherapy, mood tracking, consistent sleep schedule, and sleep apnea treatment adherence. Monitor mood stability, medication tolerability, and safety. Follow up in 2 weeks.
New Medication: Lurasidone 20 mg PO daily with food.
Activity Time: 60 minutes Complexity: Moderate CPT: 90792 ICD-10-CM: F31.32, F41.1
Case Formulation and Treatment Plan Assignment
Purpose: The purpose of this assignment is to complete a comprehensive treatment plan for a specific client (i.e., a client in your clinical practicum, a client in your place of employment, a family member or friend). Assessment, diagnosis, and treatment planning are components of the course and sections to be addressed in this assignment. You cannot use the same case used in another course.
Assignment: The student will be required to provide a DSM-5 TR diagnosis, a treatment plan and a summary integrating evidence-based literature and justifying the treatment plan the student developed for the client. The student will also cross-reference the diagnosis with the DSM 5 TR and note all patient symptoms matching criteria. Submit this assignment to the DROPBOX at the end of Unit 10.
|
Subheadings |
|
|
· Identifying information such as demographic information – age, gender, ethnicity, education (DO NOT USE FULL NAMES) · Presenting problem · Mental status description · Medical problems |
This is equal to the Introduction on the Grading Rubric |
|
· DSM 5 TR differential diagnoses with codes · Detailed treatment plan with rationale. Include · medications (psychotropic medications only). · DSM 5 TR Diagnosis compare patient symptoms with diagnostic criteria |
This is equal to the Focus & Sequencing on the Grading Rubric |
|
· Client’s strengths · Goals · Expected outcomes |
This is equal to the Conclusion on the Grading Rubric |
- Students should complete one of the essays described below. The essay is due in the individual's Assignments Folder as indicated in the Course Guide/Schedule.
- Topics.
- Article 3 response sheet question
- CJUS 410 #2
- Alcohol and Drugs
- Antitrust Practices and Market Power
- discussion
- physic problem
- Math - Education Standards
- BUS610 ORGANIZATIONAL