Age: 42 years old Background: Patricia was brought in under a emergency evaluation order after her best friend, Felicia, after the police for Patricia locking herself in a closet and screaming loudly for over an hour

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Name: Mrs. Patricia Warren
Gender: female
Age: 42 years old Background: Patricia was brought in under a emergency evaluation order after her best friend, Felicia, after the police for Patricia locking herself in a closet and screaming loudly for over an hour. EMS was able to calm her with a small dose of Ativan enroute to the emergency
department. This is Patricia’s third presentation to the emergency room in 2 weeks. She had one
psychiatric hospitalization around this same last year. No self-harm behaviors but has assaulted
other in the past. No hx of TBI. Sleeps 12-hour increments for total of 6 hrs. daily, refuses to
sleep at night. Refused vitals, wt., refuses labs, not cooperative. She obtains SSDI. She lives in
Cameron, Montana. She denies ever using any drugs and drinks one glass wine weekly. She has
a sister who is five years older, both parents deceased in the last three years. She has no children,
her husband is out of town, truck driver. Family history includes that her father had two previous
inpatient psychiatric hospitalizations for paranoia Mother had history of bipolar depression.
Paternal grandmother had “shock therapy”. Denies history of trauma experience, but her friend
reports parents death was extremely difficulty for Patricia. no current legal charges. dropped out
of high school in 11th grade, was pregnant and had abortion. allergies: Clozaril

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RUBRIC

Create documentation in the Comprehensive Psychiatric Evaluation Template about the patient you selected.

In the Subjective section, provide:
Chief complaint
History of present illness (HPI)
Past psychiatric history
Medication trials and current medications
Psychotherapy or previous psychiatric diagnosis
Pertinent substance use, family psychiatric/substance use, social, and medical history
Allergies
ROS–

Excellent 18 (18%) – 20 (20%)
The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.
Good 16 (16%) – 17 (17%)
The response accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.
Fair 14 (14%) – 15 (15%)
The response describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies.
Poor 0 (0%) – 13 (13%)
The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Or, subjective documentation is missing.
In the Objective section, provide:
Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.–

Excellent 18 (18%) – 20 (20%)
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.
Good 16 (16%) – 17 (17%)
The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.
Fair 14 (14%) – 15 (15%)
Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.
Poor 0 (0%) – 13 (13%)
The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.
In the Assessment section, provide:
Results of the mental status examination, presented in paragraph form.
At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.–

Excellent 23 (23%) – 25 (25%)
The response thoroughly and accurately documents the results of the mental status exam.

Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected.
Good 20 (20%) – 22 (22%)
The response accurately documents the results of the mental status exam.

Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the disorders selected.
Fair 18 (18%) – 19 (19%)
The response documents the results of the mental status exam with some vagueness or innacuracy.

Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vaguess or innacuracy.
Poor 0 (0%) – 17 (17%)
The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or, assessment documentation is missing.
Reflect on this case. Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).–

Excellent 9 (9%) – 10 (10%)
Reflections are thorough, thoughtful, and demonstrate critical thinking.
Good 8 (8%) – 8 (8%)
Reflections demonstrate critical thinking.
Fair 7 (7%) – 7 (7%)
Reflections are somewhat general or do not demonstrate critical thinking.
Poor 0 (0%) – 6 (6%)
Reflections are incomplete, inaccurate, or missing.
Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).–

Excellent 14 (14%) – 15 (15%)
The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making.
Good 12 (12%) – 13 (13%)
The response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study.
Fair 11 (11%) – 11 (11%)
Three evidence-based resources are provided to support assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification.
Poor 0 (0%) – 10 (10%)
Two or fewer resources are provided to support assessment and diagnosis decisions. The resources may not be current or evidence based.
Written Expression and FormattingParagraph development and organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focusedneither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.–

Excellent 5 (5%) – 5 (5%)
A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

Paragraphs and sentences follow writing standards for flow, continuity, and clarity.
Good 4 (4%) – 4 (4%)
Purpose, introduction, and conclusion of the assignment are stated, yet they are brief and not descriptive.

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time.
Fair 3.5 (3.5%) – 3.5 (3.5%)
Purpose, introduction, and conclusion of the assignment is vague or off topic.

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%-79% of the time.
Poor 0 (0%) – 3 (3%)
No purpose statement, introduction, or conclusion were provided.

Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time.
Written Expression and FormattingEnglish writing standards:
Correct grammar, mechanics, and punctuation–

Excellent 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors
Good 4 (4%) – 4 (4%)
Contains a few (one or two) grammar, spelling, and punctuation errors
Fair 3 (3%) – 3 (3%)
Contains several (three or four) grammar, spelling, and punctuation errors
Poor 0 (0%) – 2 (2%)
Contains many ( five) grammar, spelling, and punctuation errors that interfere with the readers understanding
Total Points: 100
Name: NRNP_6635_Week7_Assignment_Rubric

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