Evaluation and Patient Case Presentation Discussion

Evaluation and Patient Case Presentation Discussion

Assignment 2: Comprehensive Psychiatric

Comprehensive psychiatric evaluations are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care. Evaluation and Patient Case  For this Assignment, you will document information about a patient that you examined during the last 2 weeks, using the Comprehensive Psychiatric Evaluation
Template provided. You will then use this note to develop and record a case presentation for this patient.

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To Prepare
• Review this week’s Learning Resources and consider the insights they provide
about assessment and diagnosis. Also review the Kaltura Media Uploader resource
in the left-hand navigation of the classroom for help creating your self-recorded
Kaltura video.
• 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. When you submit your document, you should include the complete Comprehensive
Psychiatric Evaluation as a Word document, as well as a that is initialed and signed by your Preceptor. You must submit your document using Safe Assign

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. Evaluation and Patient Case  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:
• 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?
• 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?
• Reflection notes: What would you do differently in a similar patient evaluation?
Reflect on one social determinant of health according to the Healthy People 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.

Evaluation and Patient Case Presentation Discussion

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