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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.

PPT Presentation #1:  Infant or Toddler (Under Age 6)

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).  

 

 

Psychiatric Pediatric Presentation Rubric

Criteria

Ratings

Pts

Establishing Rapport - Professionalism

4 to >3 pts

Exemplary

Introduced self, including (name and role, student PMHNP).

3 to >0 pts

Developing

Introduced self, including but fails to state role (student PMHNP).

0 pts

Novice

Does not introduce him/herself (name and role).

/ 4 pts

Establishing Rapport - Professionalism

2 to >1 pts

Exemplary

Begins interview by identifying patient and caregiver’s by name.

1 to >0 pts

Developing

Begins interview by identifying patient only.

0 pts

Novice

Begins interview by identifying caregiver only.

/ 2 pts

Chief Complaint (Reason for seeking health care) – S

4 to >3 pts

Exemplary

Includes a direct quote from patient about presenting problem.

3 to >0 pts

Developing

Includes information but information is NOT a direct quote.

0 pts

Novice

Information is completely missing.

/ 4 pts

History of the Present Illness (HPI) - S

4 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 >0 pts

Developing

Includes the presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity).

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, and Severity).

/ 4 pts

Review of Systems (ROS) - S

5 to >4 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.”

4 to >0 pts

Developing

Includes 2 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

3 to >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.)

2 to >0 pts

Developing

Includes 7 or fewer 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.

/ 3 pts

Labs, Diagnostic Tests and Screening Tools - O

3 to >2 pts

Exemplary

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 to >0 pts

Developing

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 pts

Novice

Information is completely missing.

/ 3 pts

Medications-S

4 to >3.2 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 of the prescribed medications, herbal or over the counter medications).

3.2 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 prescribed medications, herbal or over the counter medications).

0 pts

Novice

Information is completely missing.

/ 4 pts

Past Medical History-S

3 to >2 pts

Exemplary

Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current

2 to >1 pts

Distinguished

Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current.

1 to >0 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 >4 pts

Exemplary

Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), and year of diagnosis.

4 to >0 pts

Developing

Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), and does not include the year of diagnosis.

0 pts

Novice

Information is completely missing.

/ 5 pts

Family Psychiatric History-S

3 to >2 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 to >0 pts

Developing

Includes an assessment of at least 3 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 to >2 pts

Exemplary

Includes all 11 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexual activity, developmental history, contraceptive use/pregnancy status, and living situation.

2 to >0 pts

Developing

Includes 6-10 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexual activity, developmental history, contraceptive use/pregnancy status, and living situation.

0 pts

Novice

Information is completely missing.

/ 3 pts

Mental Status Exam-O

15 to >12 pts

Exemplary

Includes greater than 9 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

12 to >0 pts

Developing

Includes 6-9 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

0 pts

Novice

Includes 5 or fewer 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

5 to >4 pts

Exemplary

Includes a clear outline of the accurate principal diagnosis based on DSM5-TR

4 to >0 pts

Developing

Includes a medical diagnosis based as the principal diagnosis OR the diagnosis is not a DSM5-TR diagnosis

0 pts

Novice

Information is completely missing.

/ 5 pts

Differential Diagnoses - A

3 to >2 pts

Exemplary

Includes at least 2 differential diagnoses for the principal diagnosis based on DSM5-TR

2 to >0 pts

Developing

Includes 1 differential diagnosis for the principal diagnosis OR the diagnosis is not a DSM5-TR diagnosis

0 pts

Novice

Information is completely missing.

/ 3 pts

Outcome Labs/Screening Tools - O

3 to >2 pts

Exemplary

Includes 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 to >0 pts

Developing

Includes appropriate diagnostic testing less than 50% of the time.

0 pts

Novice

Information is completely missing.

/ 3 pts

Treatment

6 to >5 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.

5 to >0 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.

0 pts

Novice

Information is completely missing.

/ 6 pts

Patient/Family Education - P

5 to >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 to >0 pts

Developing

Includes 1-2 strategies to promote and develop skills for managing their illness and at least 1 self-management method on how to incorporate healthy behaviors into their lives.

0 pts

Novice

Information is completely missing.

/ 5 pts

Professionalism

10 to >5 pts

Exemplary

The student summarized/concluded the visit at the end of the appointment, asked if there were questions before concluding appointment, demonstrated active listening. The student gave verbal/nonverbal positive reinforcement, and the information was not obtained in a logical, systematic, orderly progression.

5 to >0 pts

Developing

The student summarized/concluded the visit at the end of the appointment. The student used leading & and why questions and/or medical jargon not actively listen to the patient/parent . The student demonstrated active listening and/or the information was obtained info in logical, systematic, orderly progression.

0 pts

Novice

The student did not summarize/conclude the visit. The student was unprofessional, did not actively listen. The information was not obtained in a logical manner"

/ 10 pts

 

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