rubric4L.docx

Create documentation in the Focused SOAP Note Template about the patient in the case study.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

14 (14%) – 15 (15%)
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.

12 (12%) – 13 (13%)
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.

11 (11%) – 11 (11%)
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.

0 (0%) – 10 (10%)
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 the subjective documentation is missing.

In the Objective section, provide:• Review of Systems (ROS) documentation and relate if pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses

14 (14%) – 15 (15%)
The response thoroughly and accurately documents the patient’s ROS for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.

12 (12%) – 13 (13%)
The response accurately documents the patient’s ROS for pertinent systems. Diagnostic tests and their results are accurately documented.

11 (11%) – 11 (11%)
Documentation of the patient’s ROS is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor inaccuracies.

0 (0%) – 10 (10%)
The response provides incomplete or inaccurate documentation of the patient’s ROS. Systems may have been unnecessarily reviewed. Or the 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 diagnostic criteria for each differential diagnosis and explain what DSM-5 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.

18 (18%) – 20 (20%)
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.

16 (16%) – 17 (17%)
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.

14 (14%) – 15 (15%)
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 vagueness or innacuracy.

0 (0%) – 13 (13%)
The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or the assessment documentation is missing.

In the Plan section, provide:• Your plan for psychotherapy• Your plan for treatment and management, including alternative therapies. Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.• Incorporate one health promotion activity and one patient education strategy.

23 (23%) – 25 (25%)
The response provides an evidence-based, detailed, and appropriate plan for psychotherapy for the patient.The response provides an evidence-based, detailed, and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A strong rationale for the plan is provided that demonstrates critical thinking and content understanding.The response includes at least one evidence-based health promotion activity and one evidence-based patient education strategy.

20 (20%) – 22 (22%)
The response provides an evidence-based and appropriate plan for psychotherapy for the patient.The response provides an evidence-based and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. An adequate rationale for the plan is provided.The response includes at least one health promotion activity and one patient education strategy.

18 (18%) – 19 (19%)
The response provides a somewhat vague or inaccurate plan for psychotherapy for the patient.The response provides a somewhat vague or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is weak or general.The response includes one health promotion activity and one patient education strategy, but it may contain some vagueness or innacuracy.

0 (0%) – 17 (17%)
The response provides an incomplete or inaccurate plan for psychotherapy for the patient.The response provides an incomplete or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is inaccurate or missing.The health promotion and patient education strategies are incomplete or 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!), health promotion, and disease prevention that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

5 (5%) – 5 (5%)
Reflections are thorough, thoughtful, and demonstrate critical thinking.

4 (4%) – 4 (4%)
Reflections demonstrate critical thinking.

3.5 (3.5%) – 3.5 (3.5%)
Reflections are somewhat general or do not demonstrate critical thinking.

0 (0%) – 3 (3%)
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).

9 (9%) – 10 (10%)
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.

8 (8%) – 8 (8%)
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.

7 (7%) – 7 (7%)
Three evidence-based resources are provided to support the assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification.

0 (0%) – 6 (6%)
Two or fewer resources are provided to support the assessment and diagnosis decisions. The resources may not be current or evidence based.

Written Expression and Formatting – The paper follows correct APA format for parenthetical/in-text citations and reference list.

5 (5%) – 5 (5%)
Uses correct APA format with no errors

4 (4%) – 4 (4%)
Contains a few (one or two) APA format errors

3.5 (3.5%) – 3.5 (3.5%)
Contains several (three or four) APA format errors

0 (0%) – 3 (3%)
Contains many (five or more) APA format errors

Written Expression and Formatting – English Writing Standards:Correct grammar, mechanics, and punctuation

5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors

4 (4%) – 4 (4%)
Contains a few (one or two) grammar, spelling, and punctuation errors

3.5 (3.5%) – 3.5 (3.5%)
Contains several (three or four) grammar, spelling, and punctuation errors

0 (0%) – 3 (3%)
Contains many (five or more) grammar, spelling, and punctuation errors that interfere with the reader’s understanding