Assignment

COMPLEX CASE ASSIGNMENT

This week you participate in the final of three clinical discussions called grand rounds. When it is your week to present, you will create a focused SOAP note and a short didactic (teaching) video presenting a real (but de-identified) complex patient case from your practicum experience. 

TO PREPARE: 

· Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.

· Select an older adult patient from your clinical experience that presents with a significant concern. Create a focused SOAP note for this patient using the template in the Resources. All SOAP notes must be signed, and each page must be initialed by your Preceptor. When you submit your SOAP note, you should include the complete SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor. You must submit your SOAP note using SafeAssign. Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.

· Then, based on your SOAP note of this patient, develop a video case study presentation. Set aside time to practice what you will say beforehand and ensure that you have the appropriate lighting and equipment to record the presentation.

· Your presentation should include objectives for your audience, at least 3 possible discussion questions/prompts for your classmates to respond to, and at least 5 scholarly resources to support your diagnostic reasoning and treatment plan.

Video assignment for this week’s presenters:

Record yourself presenting the complex case study for your clinical patient. In your presentation:

· Dress professionally and present yourself in a professional manner.

· Display your photo ID at the start of the video when you introduce yourself.

· Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).

· State 3–4 objectives for the presentation that are targeted, clear, use appropriate verbs from Bloom’s taxonomy, and address what the audience will know or be able to do after viewing.

· Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.

· Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value. 

· Pose three questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.

· Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide.

· Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?

· Objective: What observations did you make during the psychiatric assessment? 

· Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with  DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms.

· Plan: What was your plan for psychotherapy (include one health promotion activity and patient education)? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.  Discuss an identified social determinate of health impacting this patient’s mental health status and provide your recommendation for a referral to assist this patient in meeting this identified need (students will need to conduct research on this topic both in the literature and for community resources).

· Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow-up, discuss what your next intervention would be.

RUBRIC

3–4 objectives provided and written in terms of what the audience will know or be able to do after viewing. Appropriate Bloom's verbs are used. Objectives are targeted and clear.

Discuss subjective data:• Chief complaint• History of present illness (HPI)• Medications• Psychotherapy or previous psychiatric diagnosis• Pertinent histories and/or ROS

The video is a Kaltura video and accurately and concisely presents the patient's subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis.

Discuss results of assessment:• Results of the mental status examination• Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.

The video accurately documents the results of the mental status exam. Video presents at least 3 differentials in order of priority for a differential diagnosis of the patient, and a rationale for their selection.... Response justifies the primary diagnosis and how it aligns with DSM-5-TR criteria.

Discuss treatment plan:• A treatment plan for the patient that addresses psychotherapy; one health promotion activity and one patient education strategy; plan for treatment and management, including alternative therapies; pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters; and a rationale for the approaches selected. Discusses an identified social determinate of health impacting this patient’s mental health status and provide your recommendation for a referral to assist this patient in meeting this identified need Edit Delete this row Add Alignments

The video clearly and concisely outlines an evidence-based treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear and concise rationale for the treatment approaches recommended is provided. Discussion includes a social determinate of health need impacting mental health status with referral recommendation and evidence of researching literature and incorporating local community resources

Reflect on this case. Discuss what you learned and what you might do differently. Pose 3 questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.

Reflections are thorough, thoughtful, and demonstrate critical thinking.... Questions or prompts for colleagues are thought-provoking and will require substantive responses and critical thinking.

Focused SOAP Note

Student chose an older adult for the case presentation....The response clearly, accurately, and thoroughly follows the SOAP format to document the selected patient case. 2 SOAP notes are submitted one in word and one pdf/images of preceptor signature.