Description
For this assignment, you will develop a presentation on a realistic clinical case on a patient that was discussed during weeks 2-6 only. Use PowerPoint feature to record (voice-over) your presentation.
Content Requirements
Students will create a PowerPoint presentation with a realistic case study and include appropriate and pertinent clinical information that will cover the following:
- Subjective data:
- Chief Complaint
- History of the Present Illness (HPI) includes the presenting problem and the 8 dimensions of the problem. See an example of the correct way to document the psychiatric HPI. Link for HPI-Successfully Capture HPI Elements in Psychiatry E/M Notes – AAPC Knowledge Center (Links to an external site.)
Elaborate on this data if it was not provided in the discussion post assignment.
- Objective data:
- Medications
- Allergies
- Past medical history
- Past psychiatric history
- Family psychiatric history
- Past surgical history
- Social history
- Labs and Screening tools
- Vital signs
Elaborate on this data if it was not provided in the discussion post assignment.
- Assessment:
- Primary Diagnosis-DSM5 only
- Differential diagnosis-DSM5 only
- Plan:
- Pharmacologic treatment plan
- Non-pharmacologic treatment plan
- Follow up plan
- Other:
- Incorporation of current clinical guidelines
- Integration of research articles
- Role of the Nurse practitioner
Submission Instructions:
- The presentation is original work and logically organized, formatted, and cited in the current APA style, including citation of references.
- The presentation should consist of 10-15 slides and less than 5 minutes in length.
- Incorporate a minimum of 4 current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work. Journal articles and books should be referenced according to APA style (the library has a copy of the APA Manual).
- Complete and submit the assignment by Sunday at 11:59 PM ET
- Late work policies, expectations regarding proper citations, acceptable means of responding to peer feedback, and other expectations are at the discretion of the instructor.
- You can expect feedback from the instructor within 48 to 72 hours from the due date.
Grading Rubric
Your assignment will be graded according to the grading rubric
| Realistic Case Presentation Rubric | ||
|---|---|---|
| Criteria | Ratings | Pts |
| Chief Complaint |
4 to >3 pts Exemplary Includes a direct quote from patient about presenting problem 3 to >2 pts Distinguished Includes a direct quote from patient and other unrelated information 2 to >0 pts Developing Includes information but information is NOT a direct quote 0 pts Novice Information is completely missing |
/ 4 pts |
|
Demographics – S |
2 pts Exemplary Begins with patient initials, age, race, ethnicity, and gender (5 demographics) 1.5 pts Distinguished Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity, and gender) 1 pts Developing Begins with 3 or less patient demographics (patient initials, age, race, ethnicity, and gender) 0 pts Novice Information is completely missing |
/ 2 pts |
|
History of the Present Illness (HPI) – S |
5 to >3 pts Exemplary Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity) 3 to >2 pts Distinguished Includes the presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing 2 to >1 pts Developing Includes the presenting problem and 4 of the 8 dimensions of the problem (OLD CARTS Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing 1 to >0 pts Novice The presenting problem is not clearly stated and/or there are < 4 of the 8 dimensions of the problem (OLD CARTS Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing |
/ 5 pts |
|
Allergies – S |
2 pts Exemplary Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy) 1.5 pts Distinguished Only screened for one type of allergy (drug, environmental, herbal, food or latex). If allergies are present, list type drug, environmental factor, herbal, food, latex name and include the severity of allergy OR description of the allergy. 1 pts Developing If allergies are present, students lists only the type of allergy name 0 pts Novice Information is completely missing |
/ 2 pts |
|
Review of Systems (ROS) – S |
5 to >3 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 3 to >2 pts Distinguished Includes 3 or fewer assessments for each body system, assesses 5-8 body systems directed to chief complaint, AND uses the words admits and denies 2 to >0 pts Developing Includes 3 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 0 pts Novice Information is completely missing |
/ 5 pts |
|
Vital Signs – O |
2 pts Exemplary Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.) 1.5 pts Distinguished Includes at least 6 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.) 1 pts Developing Includes at least 4 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.) 0 pts Novice Information is completely missing |
/ 2 pts |
|
Labs, Diagnostic Tests and Screening Tools – O |
3 pts Exemplary Includes a list of the labs, diagnostic tests, or screening tools that should be completed for identified patient that are based on the US clinical guidelines OR acknowledges no labs/diagnostic tests are recommended. 2 pts Distinguished Includes a list of the labs, diagnostic tests, or screening tools that should be completed the identified patient but they do not follow the US clinical guidelines. 1 pts Developing Includes a list of the labs, diagnostic tests, or screening tools reviewed for the identified patient but they are inappropriate or do not address the patient’s problem 0 pts Novice Information is completely missing. |
/ 3 pts |
|
Medications-S |
4 to >3 pts Exemplary Includes a list of all of the patient reported psychiatric and medical medications and the diagnosis for the medication (including name, dose, route, frequency) 3 to >2 pts Distinguished Includes a list of all of the patient reported psychiatric and but omits the medical medications and the diagnosis for the medication (including name, dose, route, frequency) 2 to >0 pts Developing Includes a list of some of the patient reported psychiatric and/or medical medications and the diagnosis for the medication (omits the dose, route, frequency of the medications) 0 pts Novice Information is completely missing |
/ 4 pts |
|
Past Medical History-S |
3 pts Exemplary Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current 2 pts Distinguished Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current 1 pts Developing Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current 0 pts Novice Information is completely missing |
/ 3 pts |
|
Past Psychiatric History-S |
5 to >3 pts Exemplary Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), year of diagnosis and 3 to >2 pts Distinguished Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (omits addiction treatment), year of diagnosis 2 to >0 pts Developing Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), does not include the year of diagnosis 0 pts Novice The information is completely missing |
/ 5 pts |
|
Family Psychiatric History-S |
3 pts Exemplary Includes an assessment of at least 6 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder and history of suicidal attempts 2 pts Distinguished Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder and history of suicidal attempts 1 pts Developing Includes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder and history of suicidal attempts 0 pts Novice Information is completely missing |
/ 3 pts |
|
Social History-S |
3 pts Exemplary Distinguished Includes all 11 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation. 2 pts Distinguished Includes at least 8 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation. 1 pts Developing Includes all 6 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation. 0 pts Novice Information is completely missing. |
/ 3 pts |
|
Mental Status Exam-O |
15 to >11 pts Exemplary Includes all 10 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with detailed descriptions for each area 11 to >7 pts Distinguished Includes all 8 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with detailed descriptions for each area 7 to >3 pts Developing Includes >6 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with some descriptions for each area 3 to >0 pts Novice Includes <3 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) OR detailed descriptions is not included for each area |
/ 15 pts |
|
Primary Diagnoses-A |
6 to >4 pts Exemplary Includes a clear outline of the accurate principal diagnosis based on DSM5 or DSM5-TR criteria 4 to >2 pts Distinguished Includes an inaccurate diagnosis as the principal diagnosis based on DSM5 or DSM5-TR criteria 2 to >0 pts Developing Includes a medical diagnosis based as the principal diagnosis OR the diagnosis is not a DSM5 or DSM5-TR diagnosis 0 pts Novice Information is completely missing |
/ 6 pts |
|
Differential Diagnoses-A |
3 pts
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