NURU-644: The Psychiatric Diagnostic Evaluation Weeks 3, 5 (100 points) and Week 7 Signature Assignment (250 points) CLOs 1-6
The Psychiatric Diagnostic Formulation is due 3 times throughout this semester – weeks 3, 5, and
www.livetext.com. The worksheet should NOT be included in the paper but is meant to be used as a guide.
This is the form you may use to help you create a formal Psychiatric Diagnostic Evaluation; it is NOT to be turned in with your assignment but just used as a guide. Following the information gleaned from a patient interview, staff or family input, and chart review; follow this outline and submit the final Psychiatric Diagnostic Evaluation, in narrative form, utilizing the worksheet (as a guide only). It should be submitted as a Word document in APA 6 format. The table includes the elements to help fulfill these assignments. Go to the instructions for what to include in each section of the notes which we used in NURU 643.
Each one of the 3 Case Formulations are to be on a different age group: you will need one on the child, one on the adolescent, one on the adult or geriatric patient. Each one will have something different at the end specific to that population that you will include either as part of the assessment or after the workup in the form of a discussion about the case. References are required for this section of your paper and then should be no more than 5 years old unless they are classics (Erikson’s developmental stages).
Worksheet for Psychiatric Diagnostic Evaluation
AUTHOR /SOURCE OF CASE PRESENTATION | |
Identifying data – Do not include any real identifying data. No names, no locations | |
SUMMARY (Up to 150
words summarizing the case presentation and outcome.) |
|
BACKGROUND (Why do
you think this case is important-why did you decide to write it up?) |
|
CASE PRESENTATION
(Presenting features, medical/social/family history.) Demographics should include: age, sex, who they live with, who they are accompanied by for your interview, who referred them to you. Payor source. |
|
Source and reliability | |
Chief Complaint of Patient: | |
History of Present Illness | |
Current Medications | |
Past Psychiatric History | |
Past Psychiatric Medications | |
Substance Use/Abuse Assessment | |
Medical History | |
Allergies | |
Family History –
Psychiatric and Addiction History. (Include Medical if Pertinent) |
|
Developmental and Social |
History | ||||
MSE: | ||||
Appearance and behavior | ||||
Motor activity | ||||
Speech | ||||
Mood | ||||
Affect | ||||
Thought content (sensorium) | ||||
Thought process | ||||
Perceptual disturbances | ||||
Cognition | ||||
Abstract Reasoning | ||||
Concentration | ||||
Impulsivity | ||||
Insight | ||||
Judgment | ||||
Threat to self or others | ||||
Motivation | ||||
Assets and Liabilities | ||||
PHYSICAL EXAM
FINDINGS (Areas of concern; address positives only) Focused and as appropriate only. Do not include entire PE unless it can be justified by patient presentation. |
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General: | ||||
HEENT: | ||||
Neck: | ||||
Chest/Lungs: | ||||
Cardiovascular | ||||
Abdomen: | ||||
Musculoskeletal: | ||||
Neurological: | ||||
Genital/Rectal: | ||||
CASE FORMULATION | ||||
DIFFERENTIAL DIAGNOSIS Formulation of diagnosis, Justification for diagnosis (what is your thinking?) – | ||||
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Treatment Plan: Include all pertinent aspects here…..
• Pharmacology |
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• Diagnostic/Lab Work if indicated
• Evidence-Based Non-Pharmacological Interventions • Patient and Family Education • Referrals
PSYCHOTHERAPY TREATMENT PLAN: Create a treatment plan regarding psychotherapy with 3 specific items. 1): 2) 3)
Must include justification and references for your decisions and suggestions |
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DISCUSSION: Discuss case hypothesis and how it fits into the treatment plan including the psychotherapy aspects
LEARNING POINTS (3-5 bullet points outlining key learning in this case.)
Strengths and deficits of Write Up
REFERENCES (APA 6 formatting, current within past 10 years.)
1 Include in your assessment a work-up and/or questions for child specific disorders. What diagnostic tests/screening tools would you use for the child?
2 Include in your treatment plan specific types of therapy that are used when working with children.
3 Address in your narrative how family structure and dynamics affects the diagnosis and treatment of children. What are the family dynamics for this patient and how does it affect the mental status of this child.
3 What developmental stage should the child be in based on chronological age and is the child in that stage?
Address parenting styles that you observed with your patient and the family and whether these were working or not working.
How does culture affect the diagnosis and treatment plan for this child?
Rubric for Week 3, 5 and Signature Assignment (SA) Week 7
Exemplary | Proficient | Developin g | Emerging | Absent | |
5 | 4 | 3 | 2 | 0 | |
Identifying data | Complete | Incomplete | Case | Background | None |
SUMMARY
BACKGROUND CASE PRESENTATION Demographics Source and reliability
5 points |
Appropriate. | Appropriate | Presentatio n not complete | not complete | present |
Exemplary | Proficient | Developin g | Emerging | Absent | |
10 | 8 | 6 | 4 | 0 | |
Chief Complaint of
Patient History of Present Illness Current Medications Past Psychiatric History Past Psychiatric Medications Substance Use/Abuse Assessment
10 points |
Complete Appropriate for this section
Quote from patient |
Incomplete Appropriate for this section
Quote from patient |
Complete Not all appropriate for this section No quote from patient | Partially complete Not all appropriate for this section No quote from patient | None
present |
Exemplary | Proficient | Developin g | Emerging | Absent | |
5 | 4 | 3 | 2 | 0 | |
Medical History
Allergies Family History – Psychiatric and Addiction History. (Include Medical if Pertinent) Developmental and Social History
DIAGNOSTIC TESTS
5 points |
Complete Appropriate for this section | Incomplete Appropriate for this section | Complete Not all appropriate for this section | Partially complete Not all appropriate for this section | None
present |
Exemplary | Proficient | Developin g | Emerging | Absent |
5 | 4 | 3 | 2 | 0 | ||
Mental Status Exam
Assets and Liabilities 5 points |
Complete Appropriate for this section | Incomplete Appropriat
e for this section |
Complete Not all appropriate for this section | Partially complete Not all appropriat e for this section | None
present |
|
Exemplary | Proficient | Developin
g |
Emerging | Absent | ||
5 | 4 | 3 | 2 | 0 | ||
PHYSICAL EXAM | Complete | Complete but | Complete | Partially | None | |
FINDINGS | and ALL | ALL sections | but ALL | complete | present | |
5 points | sections | not focused | sections | but not all | ||
focused as | appropriately. | not focused | focused as | |||
|
appropriate
|
|
as appropriate | appropriate
|
|
|
Exemplary | Proficient | Developin
g |
Emerging | Absent | ||
5 | 4 | 3 | 2 | 0 | ||
Case Formulation
Section
5 points |
Case formulation
complete; ALL discussion items focused as appropriate |
Case formulation complete; discussion findings not focused appropriatel y | Some
elements of case presentation incomplete; exam findings not focused appropriatel y |
Several elements of case presentatio n incomplete, exam lacks focus. | No case formulatio n | |
Exemplary | Proficient | Developin g | Emerging | Absent | ||
5 | 4 | 3 | 2 | 0 | ||
Differential Diagnoses
5 points |
Differential diagnoses
list complete. |
Differential diagnoses list lacks complete but lacks DSM codes | Differential diagnoses
list incomplete. |
Differentia l diagnoses
list incomplete and lacks DSM codes. |
No
Differenti al diagnoses list |
|
Exemplary | Proficient | Developin g | Emerging | Absent | ||
15 | 12 | 9 | 6 | 0 | ||
Diagnosis | Diagnosis is | Diagnosis is | Diagnosis | Diagnosis is | No |
15 points
5- accuracy 5 – both psych and medical 5 – DSM coded |
accurate, includes psychiatric and medical, psychiatric
diagnosis has DSM code |
accurate, includes psychiatric and medical, psychiatric
diagnosis has no DSM code |
is accurate, includes psychiatric but no medical, psychiatric diagnosis
has no DSM code |
not accurate, includes psychiatric but no medical, psychiatric
diagnosis has no DSM code |
diagnoses present |
Exemplary | Proficient | Developin g | Emerging | Absent | |
15 | 12 | 9 | 6 | ||
Treatment Plan –
15 points
1) Pharmacology – 3 points 2) Diagnostic/Lab Work (if indicated) – 3 points 3) Evidence-Based Non- Pharmacologic al Interventions – 3 points 4) Patient and Family Education – 3 points 5) Referrals – 3 points |
Each section complete with accurate plan | 4 sections complete with accurate plan
Or
All sections complete but not all are accurate |
3 sections complete with accurate plan
Or
Some sections complete but not all are accurate |
2 sections complete with accurate plan
Or
All sections complete but not all are accurate |
No
treatment plan |
Exemplary | Proficient | Developin g | Emerging | Absent | |
5 | 4 | 3 | 2 | 0 | |
OUTCOME AND | Complete | Complete but | Complete | Partially | None |
FOLLOW-UP | and ALL | ALL sections | but ALL | complete | present |
DISCUSSION | sections | not focused | sections | but not all | |
Signature and Date
LEARNING POINTS Strengths and deficits of Write Up REFERENCES |
focused as appropriate
|
appropriately.
|
not focused
as appropriate
|
focused as appropriate
|
|
5 points |
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Exemplary | Proficient | Developin g | Emerging | Absent | |
25 | 20 | 15 | 10 | 0 | |
Section specific to the
age group
25 points |
Complete and ALL
sections focused as appropriate Age specific questions answered and bolded area addressed |
Complete but ALL sections not focused appropriately. Age specific questions not answered and bolded area addressed | Complete but ALL sections not focused as
appropriate Age specific questions answered and bolded area not addressed |
Partially complete
but not all focused as appropriate Age specific questions not answered and bolded area not addressed |
None
present |