P5

Rubric5.docx

Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided in the Learning Resources. There is also a completed exemplar document in the Learning Resources so that you can see an example of the types of information a completed evaluation document should contain.

· Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?

· Objective: What observations did you make during the interview and review of systems?

· Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why?

· Reflection notes: What would you do differently in a similar patient evaluation?

MSE – please be thorough on this. This is the objective part of your evaluation. The Exemplar highlights the essential components of the MSE. Please read the exemplar.

Differentials – explain briefly each of your differentials and why you are choosing your primary.

Past history – give a brief description for each of the past psychiatric, substance use, medical, social and family history. Please cover at a minimum these FIVE components of past history. You are welcome if you have time to cover other past history i.e. trauma and legal.

Discussion of diagnostic with results – this is TEN points. This is 10% of your grade. Please discuss what lab work and imaging you will be considering. Why is it significant to draw certain labs and imaging? How will these results affect your diagnosis. Utilize your critical thinking. Cite your work.

FIVE scholarly, peer reviewed resources are required. Peer reviewed resources should be within 5 years of publication.

Description of chief complaint and history of present illness

5 (5%) - 5 (5%)

The student provides an accurate, clear, and complete description of the chief complaint and history of present illness.

4 (4%) - 4 (4%)

The student provides an accurate description of the chief complaint and history of present illness.

0 (0%) - 0 (0%)

0 (0%) - 3 (3%)

The student provides a vague, inaccurate, or incomplete description of the chief complaint and history of present illness, or description is missing.

Description of past psychiatric, substance use, medical, social, and family history

5 (5%) - 5 (5%)

The student provides an accurate, clear, and complete description of past psychiatric, substance use, medical, social, and family history.

4 (4%) - 4 (4%)

The student provides an accurate description of past psychiatric, substance use, medical, social, and family history.

0 (0%) - 0 (0%)

0 (0%) - 3 (3%)

The student provides a vague, inaccurate, or incomplete description of psychiatric, substance use, medical, social, and family history, or description is missing.

Discussion of most recent mental status exam and observations made during interview and review of systems

14 (14%) - 15 (15%)

The student provides an accurate, clear, and complete discussion of results from most recent mental status exam and observations made during interview and review of systems.

12 (12%) - 13 (13%)

The student provides an accurate discussion of results from most recent mental status exam and observations made during interview and review of systems.

11 (11%) - 11 (11%)

The student provides a vague, inaccurate, or incomplete discussion of results from most recent mental status exam and observations made during interview and review of systems.

0 (0%) - 10 (10%)

All or most of the discussion is inaccurate or missing.

Discussion of diagnostics with results

9 (9%) - 10 (10%)

The student provides an accurate, clear, and complete discussion of diagnostics with results.

8 (8%) - 8 (8%)

The student provides an accurate discussion of diagnostics with results.

7 (7%) - 7 (7%)

The student provides a vague, inaccurate, or incomplete discussion of diagnostics with results.

0 (0%) - 6 (6%)

All or most of the discussion is inaccurate or missing.

Diagnosis with three (3) differentials

23 (23%) - 25 (25%)

The student provides an accurate, clear, and complete diagnosis with three (3) differentials.

20 (20%) - 22 (22%)

The student provides an accurate diagnosis with three (3) differentials.

18 (18%) - 19 (19%)

The student provides a vague, inaccurate, less than 3 or incomplete diagnosis with differentials.

0 (0%) - 17 (17%)

All or most of the discussion is inaccurate or missing. Less than 2 diagnosis.

Comprehensive Psychiatric Evaluation documentation

23 (23%) - 25 (25%)

The response clearly, accurately, and thoroughly follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.