RE: PowerPoint Presentation Can you summarize the Practicum Clinical Journal #1

RE: PowerPoint Presentation
Can you summarize the Practicum Clinical Journal #1 information into a PowerPoint presentation? For the slides, I recommend about 22 substantive slides using EACH subtopic outlined in the rubric below for at least 1 substantive PP slide plus a title slide and references slides.
The chief complaint slide, for example, would only have the patient quote. If information becomes too voluminous it can be included in the slide notes.
Clinical Journal Rubric
Clinical Journal Rubric

Criteria
Ratings
Pts

Chief Complaint – Patient’s presenting complaint
view longer description
2 pts
Chief Complaints identifies reason for the visit
1 pts
Chief Complaint does not identify reason for the visit
0 pts
No Chief Complaint
1 / 2 pts

History of Present Illness – Symptom analysis for each complaint. Assessment elements to be documented will include: Associated symptoms, onset, duration, quality, severity, presence or absence of stressors, factors that alleviate or exacerbate symptoms, functional ability
view longer description
4 pts
Full symptoms assessment for each complaint
4 points
3 pts
Majority of symptom analysis is evident for each complaint
3 points
2 pts
Partial symptom analysis for each complaint
2-1
0 pts
No symptom assessment
0 points
2 / 4 pts

Psychiatric Review of Symptoms (Psych ROS) – Asks about symptoms for Depression, Mania, GAD, Panic, OCD, Trauma, Social anxiety, phobias, Hallucinations, Delusions, ADHD, disordered eating
view longer description
4 pts
Completes a full Psych ROS
4 points
3 pts
Addresses most of Psych ROS (has 7 or more components)
3 points
2 pts
Addresses partial Psych ROS (has less than 7 components)
2-1 points
0 pts
No Psych ROS
0 points
4 / 4 pts

Safety Assessment – Includes suicidal ideation/homicidal, access to weapons, past suicidal/homicidal attempts, other risk factors
view longer description
3 pts
Detailed safety assessment
3 points
2 pts
Partial Safety Assessment
2 points
1 pts
Safety Assessment needs improvement
1 point
0 pts
No safety assessment
0 Points
2 / 3 pts

Substance Abuse history – Includes detail of each substance used, last used and past interventions (rehab, groups)
view longer description
3 pts
Detailed substance abuse history
2 points
2 pts
Substance Abuse history mostly complete
2 points
1 pts
Substance Abuse history need improvement
1 point
0 pts
No substance abuse history
0 Points
2 / 3 pts

Past Psychiatric History – Includes past therapy, psychiatry, hospitalizations, past psychiatric medications
view longer description
3 pts
Detailed Past Psychiatric History
3 points
2 pts
Past Psychiatric History mostly complete
2 points
1 pts
Past Psychiatric History needs improvement
1 Point
0 pts
No Past Psychiatric History
0 Points
3 / 3 pts

Past Medical History – Includes last PE, current medical conditions, hx of surgeries, current non-psychiatric medications
view longer description
3 pts
Has detailed Past Medical History
3 Points
2 pts
Past Medical History is mostly complete
2 points
1.2 pts
Past Medical History needs improvement
1 point
0 pts
No Past Medical History
0 Points
3 / 3 pts

Medical Review of Systems – Includes Constitution, EENT, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal, Integumentary, Endocrine, Neurological, Immunological, Reproductive, and Hematological Systems
view longer description
3 pts
Has >90% of Medical Review of Systems accurately documented
3 points
2 pts
Has 50% of Medical ROS accurately documented
2 Points
1 pts
Has less than 50% of Medical ROS or system documentation is very limited
1 Point
0 pts
No Family History
0 Points
3 / 3 pts

Family History – Includes family psychiatric and pertinent medical history, family substance abuse, family legal history, family SI/HI history
view longer description
3 pts
Has complete Family history
3 points
2 pts
Family history mostly complete
2 points
1 pts
Family History needs improvement
1 point
0 pts
No Family History
0 Points
3 / 3 pts

Developmental History – Includes childhood development, childhood home atmosphere, educational history, employment history
view longer description
3 pts
Has complete Developmental History
3 Points
2 pts
Developmental History is mostly complete
2 Points
1 pts
Developmental History needs improvement
1 Point
0 pts
No Developmental History
0 Points
3 / 3 pts

Social History – Includes relationship (SO, Family), current supports, spirituality, hobbies, future plans
view longer description
3 pts
Has full Social History
3 Points
2 pts
Has most of Social History
2 points
1 pts
Social History needs improvement
1 Point
0 pts
No Social History
0 points
3 / 3 pts

PE & Objective Information Includes VS, Wt/Ht, BMI, Labs and any other pertinent information (i.e. screenings if present) If labs are not available, documents what labs they would like to see for this patient
view longer description
2 pts
Full PE and labs documented
2 points
1 pts
Partial PE
1 Points
0 pts
No PE or Labs
0 Points
2 / 2 pts

Mental Status Examination (MSE) – Includes Appearance, Behavior, Attitude, Speech, Affect, Mood, Thought Process & Content, Attention, Memory, Orientation, Memory, Abstraction, Intelligence, Insight, Judgment
view longer description
8 pts
Complete components of MSE accurately
8 Points
6 pts
Documents the majority of MSE components accurately
7-6 Points
4 pts
Documents half the components of MSE accurately
5-4 Points
2 pts
Documents less than half MSE components accurately
2-1 Points
0 pts
No MSE
0 Points
6 / 8 pts

Diagnostic Formulation – The diagnosis(es) flow from the histories and exam. Each diagnosis has rationale and supporting evidence taken from the histories/Exam
view longer description
18 pts
>90% diagnosis(es) are addressed in a clear and organized manner, including rationale for each Dx that is supported by the histories/exam
18 Points
11 pts
Majority of diagnosis(es) are addressed in a clear and organized manner, limited rationale or supporting evidence for each Dx
17-11 Point
6 pts
Diagnosis(es) addressed but lacking organization and wordy, no rationale for each Dx
10-6 Points
1 pts
Diagnosis(es) identified in brief manner; No rationale for each Dx OR inaccurate Dx
5-1 Points
0 pts
No Diagnostic Formunlation
0 Points
11 / 18 pts

Differential Diagnosis(es) – Includes possible diagnosis(es) identified in histories but missing criteria to rule in completely, gives rationale for each DDx
view longer description
10 pts
All Differential Diagnosis(es) identified from the history and rationale is documented in a clear and concise manner
10 Points
5 pts
Partial Differential Diagnosis(es) identified from the histories and rationale documented in a clear and concise manner
9-5 Points
1 pts
Has limited rationale documented for identified DDx
4-1 Points
0 pts
No DDx identified
0 Points
4 / 10 pts

Problem List – Includes the ICD-10 and DSM diagnostic codes for all Dx, DDx and medical dx identified
view longer description
2 pts
All codes are listed for identified Dx & DDx
2 Points
1 pts
Missing ICD-10 and DSM codes
1 Point
0 pts
No Codes Listed
0 points
Comments
Make the problem list just a list with ICD’s
1 / 2 pts

Treatment Planning: Pharmacological – Identifies appropriate medication(s) for identified Diagnosis(es); Written as a script, including medication name, dose, sig, refills
view longer description
4 pts
Has appropriate use of pharmacological intervention written in the form of script
4 Points
2 pts
Has medication identified but missing dose and sig OR Potential dangerous interactions with other medications
Points 3-2
1 pts
Incorrect use or incorrect dose of medication(s) OR possible contraindications
1 Point
0 pts
No medications identified
0 Points
4 / 4 pts

Treatment Planning: Non-pharmacological – Includes referrals, therapies, other interventions (i.e. exercise, support groups)
view longer description
4 pts
Identifies comprehensive list of non-pharmacological interventions for pt need
4 Points
1 pts
Identified Partial list of non-pharmacological interventions for pt need
3-1 Points
0 pts
No Non-pharmacological Interventions identified
0 Points
4 / 4 pts

Treatment Planning: Education – Includes disease prognosis, medication education (side effects, administration, off label use), safety planning, nutrition, sleep hygiene, how to reach provider….
view longer description
4 pts
Addresses all educational needs
4 Points
2 pts
Addresses the majority of educational needs
3-2 Points
1 pts
Educational needs addressed but needs improvement
1 Point
0 pts
No educational needs addressed
0 Points
4 / 4 pts

Psychopharmacology Rationale (Psychiatric Meds Only) – Thorough explanation that includes medication class, mechanism of action, side effects, black box warnings, contraindications. Also includes rationale as to why each medication was chosen for this patient. Uses high quality evidence based resources to support medication choices
view longer description
5 pts
Includes all elements listed and full rationale for medication(s) chosen
5 Points
4 pts
Includes most elements addressed and rationale for medication(s) chosen
4 Points
3 pts
For each medication chosen has several missing elements and/or brief to no rationale
3-1 Points
0 pts
No psychopharmacology rationale provided
0 Points
5 / 5 pts

Reflection and Supervision Log – Reflection includes what you have learned from clinical encounter, questions regarding clinical issues, thoughts on challenges, problems, successes, and your progress toward Class Objectives Supervision includes the number of hours of supervision obtained since your last clinical journal and a summary of what was discussed with your preceptor
view longer description
3 pts
Includes both Weekly Reflection that includes progress toward clinical objectives and Supervision Log
3 Points
2 pts
Includes weekly reflection and Supervision logs, does not address progress toward clinical objectives
2 Points
1.8 pts
Missing either Weekly Reflection or Clinical Supervision Log
1 Point
0 pts
No Weekly Reflection or Clinical Supervision Log
0 Points
3 / 3 pts

Overall Note – Note is organized, succinct, clear understanding of subjective and objective data. Grammar and punctuation are correct. If references used, APA format is correct
view longer description
6 pts
Note is organized, succinct, clear understanding of subjective and objective data. Grammar and punctuation are correct
6 Points
3 pts
Note is somewhat organized, succinct, clear understanding of subjective and objective data. And/or mistakes in grammar and punctuation, if references used has mistakes in APA format
5-1
0 pts
Poor organization of note, use of grammar/puncuation
0 Points
3 / 6 pts

Total Points: 76

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