LUIS PP SOAP

NUR-630-AP3.26/SU1 Assignments Presenta!on #1: Infant or Toddler Immersive Reader

Presenta!on #1: Infant or Toddler 90 Points Possible

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Due: Sun May 31, 2026 11:59pm

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

Step 1: For this assignment, students will create a video presenta!on performing a comprehensive psychiatric evalua!on 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 pa!ents, 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 pa!ent and the parent ques!ons the same way you do with your pa!ents in the clinic. Both should be available virtually or in-person to answer ques!ons. You may use a Zoom/video call to assess the simulated pa!ent 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 informa"on asked in the video will be used for grading.

Use the rubric as a guide for collec!ng data. Don't miss points because something was not addressed.

Use Canvas Studio's Screen Capture feature to record (voice and video) your presenta!on. No other medium will be accepted. Upload the comprehensive psychiatric examina!on document. Your documenta!on will be graded on what you asked during the session. The instruc!ons for crea!ng the video are listed below:

How do I record a Canvas Studio video with a webcam in a course?

Step 2: Each student will create a focused SOAP note or PowerPoint presenta!on. SOAP is an acronym that stands for Subjec!ve, Objec!ve, Assessment, and Plan. The comprehensive psychiatric SOAP note or PowerPoint is to be wri"en using the a"ached template below. Do not provide a voiceover or video for the PowerPoint. Only the informa"on asked in the video will be used for grading.

S = Subjec!ve data: Pa!ent’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presen!ng problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS). Click here for more details

O = Objec!ve data: Medica!ons; 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 differen!al diagnoses including ICD-10 and DSM5 codes

P = Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnos!c tes!ng/screening tools, pa!ent/family teaching, referral, and follow up

Other: Incorporate current clinical guidelines NIH Clinical Guidelines or APA Clinical Guidelines , research ar!cles, and the role of the PMHNP in your presenta!on.

Psychiatric Assessment of Infants and Toddlers Psychiatric Assessment of Children and Adolescents

Reminder: It is important that you complete this assessment using your cri!cal 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 evalua!on is listed below. It is not acceptable to document “within normal limits.”

Graduate Mental Status Exam Guide

Submission Instruc"ons:

In addi!on to the video demonstra!ng proficiency in comple!ng a comprehensive psychiatric evalua!on, students must upload a comprehensive wri"en submission.

The wri"en submission should be limited to PowerPoint 10-12 slides or a comprehensive psychiatric note and include all sec!ons of the SOAP note listed above. The comprehensive psychiatric examina!on is original work and logically organized, forma"ed, and cited in the current APA style, including cita!on of references. Incorporate a minimum of four current (published within the last five years) scholarly journal ar!cles or primary legal sources (statutes, court opinions) within your work. Journal ar!cles and books should be referenced according to APA style, 7th Edi!on (the library has a copy of the APA Manual). Students must wear their lab coats, display their STU or other iden!fica!on, and conduct the video in a professional se%ng, or the presenta!on will not be graded. Complete and submit the assignment by 11:59 PM ET Sunday

Grading Rubric

Your assignment will be graded according to the grading rubric.

View Rubric

Psychiatric Pediatric Presenta"on Rubric

Criteria Ra"ngs Points

Establishing Rapport - Professionalism /4 pts

Establishing Rapport - Professionalism /2 pts

Chief Complaint (Reason for seeking health care) – S

/4 pts

History of the Present Illness (HPI) - S

/4 pts

Review of Systems (ROS) - S

/5 pts

Vital Signs - O

/3 pts

Labs, Diagnos"c Tests and Screening Tools - O

/3 pts

Medica"ons-S

/4 pts

Past Medical History-S

/3 pts

Past Psychiatric History-S

/5 pts

Family Psychiatric History-S

/3 pts

Social History- S

/3 pts

Mental Status Exam-O

/15 pts

Primary Diagnoses - A

/5 pts

Differen"al Diagnoses - A

/3 pts

Outcome Labs/Screening Tools - O

/3 pts

Treatment

/6 pts

Pa"ent/Family Educa"on - P

/5 pts

Professionalism

/10 pts

Exemplary

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

4 to >3 pts

Developing

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

3 to >0 pts

Novice

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

0 pts

Exemplary

Begins interview by iden!fying pa!ent and caregiver’s by name.

2 to >1 pts

Developing

Begins interview by iden!fying pa!ent only.

1 to >0 pts

Novice

Begins interview by iden!fying caregiver only.

0 pts

Exemplary

Includes a direct quote from pa!ent about presen!ng problem.

4 to >3 pts

Developing

Includes informa!on but informa!on is NOT a direct quote.

3 to >0 pts

Novice

Informa!on is completely missing.

0 pts

Exemplary

Includes the presen!ng problem and the 8 dimensions of the problem (OLD CARTS – Onset, Loca!on, Dura!on, Character, Aggrava!ng factors, Relieving factors, Timing and Severity).

4 to >3 pts

Developing

Includes the presen!ng problem and 6 of the 8 dimensions of the problem (OLD CARTS – Onset, Loca!on, Dura!on, Character, Aggrava!ng factors, Relieving factors, Timing and Severity).

3 to >0 pts

Novice

The presen!ng problem is not clearly stated and/or there are < 4 of the 8 dimensions of the problem (OLD CARTS – Onset, Loca!on, Dura!on, Character, Aggrava!ng factors, Relieving factors, Timing, and Severity).

0 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.”

5 to >4 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.”

4 to >0 pts

Novice

Informa!on is completely missing.

0 pts

Exemplary

Includes all 8 vital signs, (BP (with pa!ent posi!on), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collec!on), weight, height, BMI (or percen!les for pediatric popula!on) and pain.)

3 to >2 pts

Developing

Includes 7 or fewer vital signs, (BP (with pa!ent posi!on), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collec!on), weight, height, BMI (or percen!les for pediatric popula!on) and pain.)

2 to >0 pts

Novice

Informa!on is completely missing.

0 pts

Exemplary

Includes a list of the labs, diagnos!c tests or screening tools reviewed at the visit, values of lab results or screening tools, and highlights abnormal values, OR acknowledges no labs/diagnos!c tests were reviewed.

3 to >2 pts

Developing

Includes a list of the labs, diagnos!c tests, or screening tools reviewed at the visit but does not include the values of the results or highlight abnormal values.

2 to >0 pts

Novice

Informa!on is completely missing.

0 pts

Exemplary

Includes a list of all of the pa!ent reported psychiatric and medical medica!ons and the diagnosis for the medica!on (including name, dose, route, frequency of the prescribed medica!ons, herbal or over the counter medica!ons).

4 to >3.2 pts

Developing

Includes a list of some of the pa!ent reported psychiatric and/or medical medica!ons and the diagnosis for the medica!on (omits the dose, route, frequency of the prescribed medica!ons, herbal or over the counter medica!ons).

3.2 to >0 pts

Novice

Informa!on is completely missing.

0 pts

Exemplary

Includes (Major/Chronic, Trauma, Hospitaliza!ons), for each medical diagnosis, year of diagnosis and whether the diagnosis is ac!ve or current

3 to >2 pts

Dis"nguished

Includes (Major/Chronic, Trauma, Hospitaliza!ons), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is ac!ve or current.

2 to >1 pts

Developing

Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is ac!ve or current.

1 to >0 pts

Novice

Informa!on is completely missing.

0 pts

Exemplary

Includes (Outpa!ent and Hospitaliza!ons), for each psychiatric diagnosis (including addic!on treatment), and year of diagnosis.

5 to >4 pts

Developing

Includes (Outpa!ent and Hospitaliza!ons), for each psychiatric diagnosis (including addic!on treatment), and does not include the year of diagnosis.

4 to >0 pts

Novice

Informa!on is completely missing.

0 pts

Exemplary

Includes an assessment of at least 6 family members regarding, at a minimum, gene!c disorders, mood disorder, bipolar disorder and history of suicidal a"empts

3 to >2 pts

Developing

Includes an assessment of at least 3 family members regarding, at a minimum, gene!c disorders, mood disorder, bipolar disorder and history of suicidal a"empts

2 to >0 pts

Novice

Informa!on is completely missing.

0 pts

Exemplary

Includes all 11 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupa!on, sexual orienta!on, sexual ac!vity, developmental history, contracep!ve use/pregnancy status, and living situa!on.

3 to >2 pts

Developing

Includes 6-10 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupa!on, sexual orienta!on, sexual ac!vity, developmental history, contracep!ve use/pregnancy status, and living situa!on.

2 to >0 pts

Novice

Informa!on is completely missing.

0 pts

Exemplary

Includes greater than 9 components of the mental status exam (appearance, a%tude/behavior, mood, affect, speech, thought process, thought content/ percep!on, cogni!on, insight and judgement) with detailed descrip!ons for each area

15 to >12 pts

Developing

Includes 6-9 components of the mental status exam (appearance, a%tude/behavior, mood, affect, speech, thought process, thought content/ percep!on, cogni!on, insight and judgement) with some descrip!ons for each area

12 to >0 pts

Novice

Includes 5 or fewer components of the mental status exam (appearance, a%tude/behavior, mood, affect, speech, thought process, thought content/ percep!on, cogni!on, insight and judgement) OR detailed descrip!ons is not included for each area

0 pts

Exemplary

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

5 to >4 pts

Developing

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

4 to >0 pts

Novice

Informa!on is completely missing.

0 pts

Exemplary

Includes at least 2 differen!al diagnoses for the principal diagnosis based on DSM5-TR

3 to >2 pts

Developing

Includes 1 differen!al diagnosis for the principal diagnosis OR the diagnosis is not a DSM5-TR diagnosis

2 to >0 pts

Novice

Informa!on is completely missing.

0 pts

Exemplary

Includes appropriate diagnos!c/lab tes!ng or screening tool 100% of the !me OR acknowledges “no diagnos!c tes!ng or screening tool clinically required at this !me”

3 to >2 pts

Developing

Includes appropriate diagnos!c tes!ng less than 50% of the !me.

2 to >0 pts

Novice

Informa!on is completely missing.

0 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, dura!on and cost as well as educa!on related to pharmacologic agent. For non- pharmacological treatment, includes: treatment name, frequency, dura!on. If the diagnosis is a chronic problem, student includes instruc!ons on currently prescribed medica!ons as above.

6 to >5 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, dura!on and cost as well as educa!on related to pharmacologic agent. Non- pharmacological treatment NOT included. If the diagnosis is a chronic problem, student includes instruc!ons on currently prescribed medica!ons as above.

5 to >0 pts

Novice

Informa!on is completely missing.

0 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.

5 to >3 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.

3 to >0 pts

Novice

Informa!on is completely missing.

0 pts

Exemplary

The student summarized/concluded the visit at the end of the appointment, asked if there were ques!ons before concluding appointment, demonstrated ac!ve listening. The student gave verbal/nonverbal posi!ve reinforcement, and the informa!on was not obtained in a logical, systema!c, orderly progression.

10 to >5 pts

Developing

The student summarized/concluded the visit at the end of the appointment. The student used leading & and why ques!ons and/or medical jargon not ac!vely listen to the pa!ent/parent . The student demonstrated ac!ve listening and/or the informa!on was obtained info in logical, systema!c, orderly progression.

5 to >0 pts

Novice

The student did not summarize/conclude the visit. The student was unprofessional, did not ac!vely listen. The informa!on was not obtained in a logical manner"

0 pts

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