Rewatch the same
Patient Interview
. This time, you will focus on writing the diagnosis and differential discussion. The discussion should include the following sections:
· A summary of findings
· Psychodynamic formulation
· Primary diagnosis with ICD code
· Prognosis
· Plan including medications, labs, therapy, patient education, follow up, non-pharmacological treatments
An example is outlined on page 24 of Kaplan & Sadock’s Synopsis of Psychiatry textbook.
Rubric
Psychiatric Report: Impression: Diagnosis/Differentials
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Psychiatric Report: Impression: Diagnosis/Differentials
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Criteria
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Ratings
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Pts
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This criterion is linked to a Learning OutcomeAssessment & Diagnoses
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15 pts
Proficient
Identifies the most appropriate primary diagnosis and ICD code for the patient presented in the scenario. Identifies all additional psychiatric and medical diagnoses presented in the scenario.
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11.25 pts
Acceptable
The primary diagnosis and ICD code identified is similar to the most appropriate diagnosis. At least one additional psychiatric and medical diagnosis presented in the scenario was identified.
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7.5 pts
Needs Improvement
The primary diagnosis and ICD code identified is vague or not similar to the most appropriate diagnosis. The additional psychiatric and medical diagnosis presented in the scenario was not correct.
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3.75 pts
Unsatisfactory
The primary diagnosis and ICD code identified is not correct for the patient presented in the scenario. No additional psychiatric or medical diagnoses presented in the scenario were identified.
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0 pts
Missing
No primary diagnoses, ICD code, secondary, or medical diagnoses were given.
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15 pts
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This criterion is linked to a Learning OutcomeDifferential Diagnoses
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15 pts
Proficient
Identifies at least 2 appropriate differential diagnoses for the patient presented in the scenario.
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11.25 pts
Acceptable
Identifies at least 1 appropriate differential diagnosis for the patient presented in the scenario.
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7.5 pts
Needs Improvement
Identifies at least 1 differential diagnosis that is not clearly related to the patient presented in the scenario.
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3.75 pts
Unsatisfactory
The differential diagnosis presented is incorrect or is unrelated to the patient presented in the scenario.
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0 pts
Missing
Does not provide differential diagnoses.
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15 pts
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This criterion is linked to a Learning OutcomeImpression
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20 pts
Proficient
Provides a concise discussion of the of the diagnosis and supporting evidence. The differential diagnoses are presented. The treatment plan is logically presented.
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15 pts
Acceptable
Provides a discussion of the of the diagnosis with some supporting evidence. The differential diagnoses may be presented. The treatment plan is briefly presented.
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10 pts
Needs Improvement
The discussion of the diagnosis may be vague or lack supporting evidence. The differential diagnoses may not be presented. The treatment plan is not clearly presented.
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5 pts
Unsatisfactory
The discussion of the diagnosis is unclear and lacks supporting evidence. The differential diagnoses are not presented. The treatment plan is incorrect and is not clearly presented.
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0 pts
Missing
No impression provided .
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20 pts
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This criterion is linked to a Learning OutcomePlan- Medications & Labs
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20 pts
Proficient
Describes a detailed plan for medications and laboratory orders that are clearly related to the primary diagnosis. The medications include all prescribing details.
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15 pts
Acceptable
Describes a detailed plan for medications and laboratory orders. There may be areas that are vague or not clearly relevant to the primary diagnosis.
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10 pts
Needs Improvement
Describes a general plan for medications and laboratory orders. There are several key missing details or items not relevant to the primary diagnosis.
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5 pts
Unsatisfactory
Describes a general plan for medications and laboratory orders that is incorrect for the primary diagnosis.
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0 pts
Missing
No medications and laboratory provided.
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20 pts
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This criterion is linked to a Learning OutcomePlan- Therapy, Education, Follow up, Non- Pharmacological
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20 pts
Proficient
Provides an individualized plan that addresses all sections with evidence-based interventions for the identified primary diagnosis: therapy, education, follow up/ referrals, and non-pharmacologic interventions.
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15 pts
Acceptable
Most sections of the plan are addressed.
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10 pts
Needs Improvement
Some sections of the plan are addressed.
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5 pts
Unsatisfactory
Most sections of the plan are not addressed.
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0 pts
Missing
No therapy, education, follow up/ referrals, and non-pharmacologic interventions are provided.
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20 pts
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This criterion is linked to a Learning OutcomeOrganization
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5 pts
Proficient
All data and information is placed in the correct section of the note. The note is well organized and clear.
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3.75 pts
Acceptable
Minor mistakes in placement of information and data. The note is mostly organized and clear.
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2.5 pts
Needs Improvement
Several mistakes in placement of information and data that impact the organization and clarity of the note.
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1.25 pts
Unsatisfactory
Numerous mistakes in placement of information. The note is not well organized and is difficult to understand.
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0 pts
Missing
Information unreadable, multiple mistakes in organization of data, information is unclear.
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5 pts
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This criterion is linked to a Learning OutcomeTerminology
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5 pts
Proficient
Appropriate use of medical terminology. No grammar/ spelling mistakes.
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3.75 pts
Acceptable
Minor mistakes with terminology, spelling or grammar.
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2.5 pts
Needs Improvement
Several mistakes with terminology, spelling or grammar.
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1.25 pts
Unsatisfactory
Frequent mistakes with terminology, spelling or grammar that impact the reader’s ability to understand the note.
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0 pts
Missing
Information is unreadable, multiple mistakes, and the information is unclear.
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5 pts
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Total Points: 100
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IV. Summary of Findings
Summarize mental symptoms, medical and laboratory findings, and psychological and neurologic test results, if available; include medications patient has been taking, dosage, duration. Clarity of thinking is reflected in clarity of writing. When summarizing the mental status (e.g., the phrase “Patient denies hallucinations and delusions” is not as precise as “Patient denies hearing voices or thinking that he is being followed.”). The latter indicates the specific question asked and the specific response given. Similarly, in the conclusion of the report one would write “Hallucinations and delusions were not elicited.”
V. Diagnosis
Diagnostic classification is made according to DSM-5. The diagnostic numerical code should be used from DSM-5 or ICD-10. It might be prudent to use both codes to cover current and future regulatory guidelines.
VI. Prognosis
Opinion about the probable future course, extent, and outcome of the disorder; good and bad prognostic factors; specific goals of therapy
VII. Psychodynamic Formulation
Causes of the patient’s psychodynamic breakdown—influences in the patient’s life that contributed to present disorder; environmental, genetic, and personality factors relevant to determining patient’s symptoms; primary and secondary gains; outline of the major defense mechanism used by the patient
VIII. Comprehensive Treatment Plan
Modalities of treatment recommended, role of medication, inpatient or outpatient treatment, frequency of sessions, probable duration of therapy; type of psychotherapy; individual, group, or family therapy; symptoms or problems to be treated. Initially, treatment must be directed toward any life-threatening situations such as suicidal risk or risk of danger to others that require psychiatric hospitalization. Danger to self or others is an acceptable reason (both legally and medically) for involuntary hospitalization. In the absence of the need for confinement, a variety of outpatient treatment alternatives are available: day hospitals, supervised residences, outpatient psychotherapy or pharmacotherapy, among others. In some cases, treatment planning must attend to vocational and psychosocial skills training and even legal or forensic issues.
Comprehensive treatment planning requires a therapeutic team approach using the skills of psychologists, social workers, nurses, activity and occupational therapists, and a variety of other mental health professionals, with referral to self-help groups (e.g., Alcoholics Anonymous [AA]) if needed. If either the patient or family members are unwilling to accept the recommendations of treatment and the clinician thinks that the refusal of the recommendations may have serious consequences, the patient, parent, or guardian should sign a statement to the effect that the recommended treatment was refused.
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Week4paperinstructions.docx
