Step 1: For this assignment, students will create a video presentation performing a comprehensive psychiatric evaluation of an infant or toddler. You are expected to choose a child and an adult to conduct an interview with. The child and parent are not required to be actual clinic patients, but merely someone who has agreed to perform the interview with you. You will be graded on your interview skills when interviewing the persons performing as an infant or toddler and a parent. You are expected to ask the patient and the parent questions the same way you do with your patients in the clinic. Both should be available virtually or in-person to answer questions. You may use a Zoom/video call to assess the simulated patient if you do not have a child/parent you can assess face to face.
I expect that you will conduct a mental status exam during the interview. If you don’t ask it or explain how you observed it, then don’t document it. Only the information asked in the video will be used for grading.
Use the rubric as a guide for collecting data. Don’t miss points because something was not addressed.
Use Canvas Studio’s Screen Capture feature to record (voice and video) your presentation. No other medium will be accepted. Upload the comprehensive psychiatric examination document. Your documentation will be graded on what you asked during the session. The instructions for creating the video are listed below:
How do I record a Canvas Studio video with a webcam in a course?Links to an external site.
Step 2: Each student will create a focused SOAP note or PowerPoint presentation. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive psychiatric SOAP note or PowerPoint is to be written using the attached template below. Do not provide a voiceover or video for the PowerPoint. Only the information asked in the video will be used for grading.
S =
Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS). Click hereLinks to an external site. for more details
O =
Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; and Mental Status Exam
A =
Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes
P =
Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up
Other: Incorporate current clinical guidelines NIH Clinical GuidelinesLinks to an external site. or APA Clinical GuidelinesLinks to an external site., research articles, and the role of the PMHNP in your presentation.
Psychiatric Assessment of Infants and ToddlersLinks to an external site.
Psychiatric Assessment of Children and AdolescentsLinks to an external site.
Reminder: It is important that you complete this assessment using your critical thinking skills. You are expected to synthesize your clinical assessment, formulate a psychiatric diagnosis, and develop a treatment plan independently. It is not acceptable to document “my preceptor made this diagnosis.” An example of the appropriate descriptors of the clinical evaluation is listed below. It is not acceptable to document “within normal limits.”
Graduate Mental Status Exam GuideDownload Graduate Mental Status Exam Guide
Submission Instructions:
In addition to the video demonstrating proficiency in completing a comprehensive psychiatric evaluation, students must upload a comprehensive written submission.
The written submission should be limited to PowerPoint 10-12 slides or a comprehensive psychiatric note and include all sections of the SOAP note listed above.
The comprehensive psychiatric examination is original work and logically organized, formatted, and cited in the current APA style, including citation of references. Incorporate a minimum of four 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, 7th Edition (the library has a copy of the APA Manual).
Students must wear their lab coats, display their STU or other identification, and conduct the video in a professional setting, or the presentation will not be graded.
Complete and submit the assignment by 11:59 PM ET Sunday
Grading Rubric
Your assignment will be graded according to the grading rubric.
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Video Case Presentation and Psychiatric SOAP Note Rubric 2022
Video Case Presentation and Psychiatric SOAP Note Rubric 2022
Criterios Calificaciones Pts
Chief Complaint
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4 a >3 pts
Exemplary
Includes a direct quote from patient about presenting problem
3 a >2 pts
Distinguished
Includes a direct quote from patient and other unrelated information
2 a >0 pts
Developing
Includes information but information is NOT a direct quote
0 ptos.
Novice
Information is completely missing
/ 4 pts
Demographics – S
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2 ptos.
Exemplary
Begins with patient initials, age, race, ethnicity, and gender (5 demographics)
1.5 ptos.
Distinguished
Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity, and gender)
1 ptos.
Developing
Begins with 3 or less patient demographics (patient initials, age, race, ethnicity, and gender)
0 ptos.
Novice
Information is completely missing
/ 2 pts
History of the Present Illness (HPI) – S
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5 a >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 a >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 a >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 a >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
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2 ptos.
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 ptos.
Distinguished
If allergies are present, students list type Drug, environmental factor, herbal, food, latex name and include severity of allergy OR description of the allergy
1 ptos.
Developing
If allergies are present, students lists only the type of allergy name
0 ptos.
Novice
Information is completely missing
/ 2 pts
Review of Systems (ROS) - S
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5 a >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 a >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 a >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 ptos.
Novice
Information is completely missing
/ 5 pts
Vital Signs – O
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2 ptos.
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 ptos.
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 ptos.
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 ptos.
Novice
Information is completely missing
/ 2 pts
Labs, Diagnostic Tests and Screening Tools – O
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3 ptos.
Exemplary
During the visit: Includes a list of the labs, diagnostic tests or screening tools reviewed at the visit, values of lab results or screening tools, and highlights abnormal values, OR acknowledges no labs/diagnostic tests were reviewed.
2 ptos.
Distinguished
During the visit: Includes a list of the labs, diagnostic tests, or screening tools reviewed at the visit, but does not include the values of lab results or screening tools, but does not highlight abnormal values.
1 ptos.
Developing
During the visit: Includes a list of the labs, diagnostic tests, or screening tools reviewed at the visit but does not include the values of the results or highlight abnormal values.
0 ptos.
Novice
Information is completely missing.
/ 3 pts
Medications-S
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4 a >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 a >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 a >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 ptos.
Novice
Information is completely missing
/ 4 pts
Past Medical History-S
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3 ptos.
Exemplary
Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current
2 ptos.
Distinguished
Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current
1 ptos.
Developing
Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current
0 ptos.
Novice
Information is completely missing
/ 3 pts
Past Psychiatric History-S
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5 a >3 pts
Exemplary
Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), year of diagnosis and
3 a >2 pts
Distinguished
Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (omits addiction treatment), year of diagnosis
2 a >0 pts
Developing
Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), does not include the year of diagnosis
0 ptos.
Novice
The information is completely missing
/ 5 pts
Family Psychiatric History-S
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3 ptos.
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 ptos.
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 ptos.
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 ptos.
Novice
Information is completely missing
/ 3 pts
Social History-S
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3 ptos.
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 ptos.
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 ptos.
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 ptos.
Novice
Information is completely missing.
/ 3 pts
Mental Status Exam-O
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15 a >8 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
8 a >5 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
5 a >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 a >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
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5 a >3 pts
Exemplary
Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)
3 a >2 pts
Distinguished
Includes a clear outline of the accurate diagnoses addressed at the visit but does not list the diagnoses in descending order of priority
2 a >0 pts
Developing
Includes an inaccurate diagnosis as the principal diagnosis
0 ptos.
Novice
Information is completely missing
/ 5 pts
Differential Diagnoses-A
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3 ptos.
Exemplary
Includes at least 2 differential diagnoses that can be supported by the subjective and objective data provided.
2 ptos.
Distinguished
Includes 1 differential diagnosis that can be supported by the subjective and objective data provided.
1 ptos.
Developing
Includes at least 1 differential diagnosis that is NOT supported by the subjective and objective data
0 ptos.
Novice
Information is completely missing
/ 3 pts
Outcome Labs/Screening Tools – O
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3 ptos.
Exemplary
After the visit: orders appropriate diagnostic/lab testing or screening tool 100% of the time OR acknowledges “no diagnostic testing or screening tool clinically required at this time”
2 ptos.
Distinguished
After the visit: orders appropriate diagnostic/lab testing 50% of the time OR acknowledges “no diagnostic testing or screening tool clinically required at this time”
1 ptos.
Developing
After the visit, orders appropriate diagnostic testing less than 50% of the time.
0 ptos.
Novice
Information is completely missing.
/ 3 pts
Treatment
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8 a >6 pts
Exemplary
Includes a detailed pharmacologic and non pharmacological treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the following: drug/vitamin/herbal name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. For non-pharmacological treatment, includes: treatment name, frequency, duration. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. The plan is supported by the current US clinical guidelines.
6 a >4 pts
Distinguished
Includes a detailed pharmacologic and non pharmacological treatment plan for each of the diagnoses listed under “assessment”. The plan includes 4-7 of the following: drug/vitamin/herbal name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. For non-pharmacological treatment, includes: treatment name, frequency, duration. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. The plan is supported by the current US clinical guidelines.
4 a >2 pts
Developing
Includes a detailed pharmacologic and non pharmacological treatment plan for each of the diagnoses listed under “assessment”. The plan includes 4 of the following: drug/vitamin/herbal name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. Non-pharmacological treatment NOT included. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. The plan is NOT supported by the current US clinical guidelines OR is unsafe.
2 a >0 pts
Novice
Information is completely missing
/ 8 pts
Patient/Family Education-P
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5 a >3 pts
Exemplary
Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives.
3 a >2 pts
Distinguished
Includes at least 2 strategies to promote and develop skills for managing their illness and at least 2 self-management methods on how to incorporate healthy behaviors into their lives.
2 a >0 pts
Developing
Includes at least 1 strategies to promote and develop skills for managing their illness and at least 1 self-management methods on how to incorporate healthy behaviors into their lives.
0 ptos.
Novice
Information is completely missing.
/ 5 pts
Referral
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5 a >3 pts
Exemplary
Provides a detailed list of medical and other interdisciplinary referrals or documents NO REFERRAL ADVISED AT THIS TIME. Includes a timeline for follow up appointments.
3 a >2 pts
Distinguished
Provides a medical or other interdisciplinary referral or documents NO REFERRAL ADVISED AT THIS TIME. Includes a timeline for follow up appointments.
2 a >0 pts
Developing
Provides a medical or other interdisciplinary referral. DOES NOT include a timeline for follow up appointments.
0 ptos.
Novice
Information is completely missing.
/ 5 pts
APA Formatting
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5 a >3 pts
Exemplary
Effectively uses literature and other resources to inform their work. Exceptional use of citations and extended referencing. High level of precision with APA 7th Edition writing style.
3 a >2 pts
Distinguished
Effectively uses literature and other resources to inform their work. Moderate use of citations and extended referencing. Moderate level of precision with APA 7th Edition writing style.
2 a >0 pts
Developing
Ineffectively uses literature and other resources to inform their work. Moderate use of citations and extended referencing. APA 7th Edition writing style not strictly adhered to.
0 ptos.
Novice
APA style and writing mechanics not used.
/ 5 pts
Puntos totales: 0
Requirements: Read instructions
