Evaluation and Patient Case Presentation Essay

Assignment 2: Comprehensive Psychiatric
Evaluation and Patient Case Presentation
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.
For this Assignment, you will document information about a patient that you
examined during the last 5 weeks, using the Comprehensive Psychiatric Evaluation
Template provided. You will then use this note to develop and record a case
presentation for this patient. Evaluation and Patient Case Presentation Essay

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To Prepare
• Select a patient that you examined during the last 5 weeks. Review prior resources
on the disorder this patient has.
o It is recommended that you use the Kaltura Personal Capture tool to record
and upload your assignment.
o Review the Kaltura Media Uploader resource in the left-hand navigation of
the classroom for help creating your self-recorded Kaltura Personal Capture
video. The Personal Capture Quickstart Guide will walk you through creating
your video, uploading it to Blackboard and placing it into the assignment
area.
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• 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 PDF/images of each page
that is initialed and signed by your Preceptor. You must submit your document
using SafeAssign. 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 progress note 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. Evaluation and Patient Case Presentation Essay
• 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
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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. Evaluation and Patient Case Presentation Essay
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? Evaluation and Patient Case Presentation Essay
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• Objective: What observations did you make during the interview and review of
systems?
• 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? Evaluation and Patient Case Presentation Essay
• 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. Evaluation and Patient Case Presentation Essay