Order ID:89JHGSJE83839 | Style:APA/MLA/Harvard/Chicago | Pages:5-10 |
Instructions:
Assignment: Present a Patient Case
Using the Focused SOAP Note Template provided, you will document information about a patient you examined in the previous three weeks for this assignment. This note will be used to create and record a case presentation for this patient.
To Get Ready
Examine this week’s Learning Resources and think about what you’ve learned. For help creating your self-recorded Kaltura video, look at the Kaltura Media Uploader resource in the left-hand navigation of the classroom.
Choose a patient of any age (child or adult) who you have seen in the last three weeks.
Using the template provided in the Learning Resources, create a Focused SOAP Note for this patient. A completed Focused SOAP Note Exemplar is also included as a reference for assignment expectations.
Please note that all SOAP notes must be signed, and your Preceptor must initial each page. It is important to note that electronic signatures are not accepted.
When submitting your note, make sure to include the entire focused SOAP note as a Word document, as well as PDF/images of each page that your Preceptor has initialed and signed.
You must use SafeAssign to submit your SOAP note. Faculty will deduct points if both files are not received by the due date, according to the Walden Grading Policy.
Create a video case study presentation based on your SOAP note for this patient. Before you record, take some time to practice your presentation.
To support your assessment, diagnosis, and treatment planning, include at least five scholarly resources.
Make sure you have the right lighting and recording equipment for the presentation.
The Challenge
Make a video of yourself presenting your clinical patient with a complex case study. In your presentation, you should:
Wear a lab coat to look professional and present yourself in a professional manner.
When you introduce yourself at the beginning of the video, show your photo ID.
Make sure you don’t include anything that goes against HIPAA’s principles (for example, don’t use the patient’s name or any other identifying information).
Present the entire case study in its entirety. Include the chief complaint, the history of the current illness, any relevant prior psychiatric, substance use, medical, social, or family history, the most recent mental status exam, the current psychiatric diagnosis, as well as any differential diagnoses that have been ruled out, and a treatment and management plan.
Report normal diagnostic results as the test’s name and “normal” as the modifier (rather than specific value). A specific value should be reported for abnormal results.
Keep your presentation short and sweet, no more than 8 minutes. Using your SOAP note as a guide, specifically address the following for the patient:
Subjective: To arrive at your differential diagnosis, what information did the patient provide about their chief complaint and symptomology? How long have their symptoms lasted and how severe are they? What effect do their symptoms have on their daily lives?
Objective: During the psychiatric evaluation, what observations did you make?
Discuss the results of their mental status examination. What were the different diagnoses you came up with? Give at least three possible diagnoses and explain why you chose them. Order them from most important to least important. What was your primary diagnosis, and why did you choose it? Describe how your primary diagnosis is supported by the patient’s symptoms and aligns with DSM-5 diagnostic criteria.
What was your strategy for psychotherapy? What was your treatment and management strategy, including complementary and alternative therapies? Include a rationale for this treatment and management plan, as well as pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. Include at least one health promotion activity and one patient education strategy in your plan as well.
Notes for reflection: If you had the opportunity to conduct the session again, what would you do differently with this patient? If you have the opportunity to follow up with your patient, explain whether or not these interventions were successful and why. Discuss what your next intervention would be if you were unable to conduct a follow-up.
RUBRIC |
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Excellent Quality 95-100%
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Introduction
45-41 points The background and significance of the problem and a clear statement of the research purpose is provided. The search history is mentioned. |
Literature Support 91-84 points The background and significance of the problem and a clear statement of the research purpose is provided. The search history is mentioned. |
Methodology 58-53 points Content is well-organized with headings for each slide and bulleted lists to group related material as needed. Use of font, color, graphics, effects, etc. to enhance readability and presentation content is excellent. Length requirements of 10 slides/pages or less is met. |
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Average Score 50-85% |
40-38 points More depth/detail for the background and significance is needed, or the research detail is not clear. No search history information is provided. |
83-76 points Review of relevant theoretical literature is evident, but there is little integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are included. Summary of information presented is included. Conclusion may not contain a biblical integration. |
52-49 points Content is somewhat organized, but no structure is apparent. The use of font, color, graphics, effects, etc. is occasionally detracting to the presentation content. Length requirements may not be met. |
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Poor Quality 0-45% |
37-1 points The background and/or significance are missing. No search history information is provided. |
75-1 points Review of relevant theoretical literature is evident, but there is no integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are not included in the summary of information presented. Conclusion does not contain a biblical integration. |
48-1 points There is no clear or logical organizational structure. No logical sequence is apparent. The use of font, color, graphics, effects etc. is often detracting to the presentation content. Length requirements may not be met |
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Present a Patient Case |