To Prepare
· Review this week’s Learning Resources and consider the insights they provide about assessment and diagnosis. Also review the Kaltura Media resource in the Classroom Support Center (accessed via the Help button).
· Select a patient that you examined during the last 2 weeks who presented with a disorder
other than the one present in your selected case for Week 5.
· 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. All psychiatric evaluations must be signed, and each page must be initialed by your Preceptor. You will submit your document in Week 7: Assignment, Part 2 and you will include the complete Comprehensive Psychiatric Evaluation as a Word document, as well as a PDF/images of each page that is initialed and signed by your Preceptor. You must submit your document using Turn It In.
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.
· Develop a video case presentation, based on your evaluation of this patient, that includes chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis, including differentials that were ruled out.
· Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.
· Ensure that you have the appropriate lighting and equipment to record the presentation.
Assignment
Record yourself presenting the complex case for your clinical patient.
Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video.
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).
· Present the full case. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis including differentials that were ruled out.
· 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.
Be succinct in your presentation, and do not exceed 8 minutes. Address the following:
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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?
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Objective: What observations did you make during the interview and review of systems?
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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?
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Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
ATTENTION
For the Comprehensive Psychiatric Evaluations there has been some questions regarding some of the sections. As you continue to work on the Comprehensive Psychiatric Evaluations please review the following for further guidance for the sections below:
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History of Present Illness-Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. Then go on and complete a symptom analysis for your note. Explain in detail what is wrong with the patient. First what is bringing the patient to your evaluation. Then, include a PSYCHIATRIC REVIEW OF SYMPTOMS. The symptoms onset, duration, frequency, severity, and impact.
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Head Injuries-Within the Medical History section you want to rule this out, a head injury can contribute to mental health symptoms. It is very important in psychiatry that we address this with all evaluations. (For the purpose of the case studies in this course, if head injuries are not mentioned, for that section just include “no head injuries reported”)
***Refer to this regarding brain injuries and psychiatric symptoms:
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Diagnostic Results-For this section you want to also cover what labs or diagnostics are appropriate to order for the patient, not only lab results provided. For example, if a patient is experiencing depression, you want to rule out medical conditions like hypothyroidism or anemia. The labs you include in this section need to be supported with evidence and guidelines.
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Mental Status Examination-This section must cover all components, be presented in paragraph form and not use of a checklist.
***Refer to this as a resource for the MSE components:
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Screening Tools-These tools are very valuable in psychiatry. You want to include in the Comprehensive Psychiatric Evaluations what screenings tools (if any) would be appropriate.
