PRAC 6665 WEEK 3 ASSIGNMENT 2 FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION, PART 1

PRAC 6665 WEEK 3 ASSIGNMENT 2 FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION, PART 1

Subjective:

CC (chief complaint): “I have been feeling very sad and tired most of the time, and I no longer feel interested in things I used to enjoy.”

HPI: The patient is a 36-year-old male who presents with symptoms consistent with depression. The patient reports persistent sadness and emotional exhaustion for approximately two months. He explains that interest in usual activities such as spending time with family, social interaction, and hobbies has decreased. The patient reports difficulty concentrating at work and reduced motivation to complete daily tasks. Sleep has been disrupted with difficulty falling asleep and waking several times during the night. The patient reports reduced appetite and mild weight loss during the past few weeks. He also reports feelings of hopelessness and low self-worth at times. The patient denies suicidal ideation, self-harm thoughts, or previous suicide attempts. Symptoms started gradually and have become more noticeable over the past several weeks.

Substance Current Use: The patient reports occasional alcohol use during social events, approximately one to two drinks per week. The patient denies tobacco use, vaping, marijuana use, or other illicit substances. The patient reports drinking one cup of coffee daily.

Medical History: The patient has a history of arthritis diagnosed three years ago and experiences intermittent joint pain, particularly in the knees and hands. The patient denies a history of hypertension, diabetes, or cardiovascular disease. No previous psychiatric hospitalization has been reported.

• Current Medications: Naproxen 250 milligrams orally twice daily for arthritis pain
• Allergies: The patient reports no known drug allergies.
• Reproductive Hx: The patient reports being sexually active with one partner. The patient has two children and denies a history of reproductive health problems or sexually transmitted infections.

ROS

GENERAL: The patient reports persistent fatigue, low energy, and decreased appetite during the past two months. Mild unintentional weight loss has been reported. The patient denies fever, chills, or night sweats.

HEENT: The patient denies headaches, dizziness, visual changes, hearing problems, nasal congestion, or sore throat.

SKIN: The patient denies rashes, itching, lesions, or discoloration of the skin.

CARDIOVASCULAR: The patient denies chest pain, palpitations, shortness of breath with activity, or swelling of the lower extremities.

RESPIRATORY: The patient denies cough, wheezing, shortness of breath, or difficulty breathing.

GASTROINTESTINAL: The patient reports decreased appetite. The patient denies nausea, vomiting, abdominal pain, diarrhea, or constipation.

GENITOURINARY: The patient denies pain during urination, urinary frequency, urgency, hematuria, or incontinence.

NEUROLOGICAL: The patient reports reduced concentration and decreased focus. The patient denies seizures, weakness, numbness, or dizziness.

MUSCULOSKELETAL: The patient reports intermittent joint pain related to arthritis, mainly affecting the knees and hands. The patient denies muscle weakness or recent injury.

HEMATOLOGIC: The patient denies abnormal bleeding, bruising, or previous diagnosis of blood disorders.

LYMPHATICS: The patient denies swelling or tenderness of lymph nodes.

ENDOCRINOLOGIC: The patient denies excessive thirst, excessive urination, heat intolerance, or cold intolerance.

Objective:

Vitals: Temp: 98.2°F, BP: 120/76 mmHg, Pulse: 74 bpm, RR: 18/min, SpO₂: 99%, Ht: 5 ft 10 in, Wt: 174 lb, BMI: 24.9

GENERAL: The patient was cooperative and oriented to person, place, time, and situation. The patient appeared fatigued but was in no acute distress.

HEENT: Head was normocephalic and atraumatic. Pupils were equal, round, and reactive to light and accommodation. Extraocular movements were intact. Oral mucosa was moist with no lesions.

SKIN: Skin was warm, dry, and intact with no rashes or lesions observed.

CARDIOVASCULAR: Heart rate was regular with normal S1 and S2 heart sounds. No murmurs, rubs, or gallops were noted. Peripheral pulses were present and symmetrical.

RESPIRATORY: Lung sounds were clear bilaterally. No wheezes, crackles, or rhonchi were present. Respirations were even and unlabored.

GASTROINTESTINAL: Abdomen was soft, non tender, and non distended. Bowel sounds were present in all quadrants.

GENITOURINARY: No suprapubic tenderness or flank tenderness was noted.

NEUROLOGICAL: The patient was alert and oriented to person, place, time, and situation. Cranial nerves were grossly intact. Motor strength was normal in the upper and lower extremities.

MUSCULOSKELETAL: Mild tenderness was noted in bilateral knee joints and hand joints consistent with arthritis. Range of motion was slightly reduced due to joint discomfort.

Psychiatric: Mood appeared depressed with constricted affect. Speech was clear but slow. Thought process was logical and organized. The patient denied suicidal or homicidal ideation. Insight and judgment were fair.

Diagnostic results:

Depression screening using the Patient Health Questionnaire-9 produced a score of 16

Assessment:

Mental Status Examination:

The patient appeared well-groomed and appropriately dressed for the visit. Behavior was calm and cooperative during the interview. Eye contact was limited but appropriate. Speech was clear, coherent, and slightly slowed in rate. Mood was reported as sad, and affect appeared constricted and congruent with the stated mood. Thought process was logical, organized, and goal-directed. Thought content showed no evidence of delusions, hallucinations, or paranoia. The patient denied suicidal ideation and homicidal ideation. Attention and concentration were mildly reduced during the conversation. Memory appeared intact for recent and remote events. Insight into the current condition was fair, and judgment was considered appropriate. The patient was alert and oriented to person, place, time, and situation.

Diagnostic Impression:

1. Major Depressive Disorder (F32.1)
   Major depressive disorder was considered the most likely diagnosis because the patient presented with several symptoms commonly associated with depressive disorders. The patient reported persistent sadness, decreased interest in previously enjoyable activities, fatigue, decreased appetite, sleep disturbance, weight loss, and difficulty concentrating. These symptoms have been present for approximately two months and have affected the patient’s daily functioning and productivity at work. The patient denied substance use or another medical condition that could explain the symptoms. There was also no history of manic or hypomanic episodes. According to the DSM-5, a diagnosis of major depressive disorder requires the presence of at least five symptoms during the same two-week period, with at least one symptom being depressed mood or loss of interest or pleasure in activities (American Psychiatric Association, 2022). Due to the number of depressive symptoms present and the duration exceeding two weeks, major depressive disorder with moderate severity was considered the highest priority diagnosis.
2. Persistent Depressive Disorder (Dysthymia) (F34.1)
   Persistent depressive disorder was also considered because the patient reported low mood, fatigue, reduced energy, and decreased interest in activities. This disorder involves chronic depressive symptoms that persist for long periods (Goncalves et al., 2023). Patients may experience poor appetite, sleep disturbance, low self-esteem, and reduced concentration. However, persistent depressive disorder requires symptoms to be present for at least two years in adults according to DSM-5 criteria. The patient reported symptoms for approximately two months.
3. Adjustment Disorder with Depressed Mood (F43.21)
   Adjustment disorder with depressed mood was also considered because the patient described experiencing increased work-related stress and personal challenges prior to the onset of symptoms. Adjustment disorder occurs when emotional or behavioral symptoms develop in response to an identifiable stressor. Symptoms may include sadness, difficulty concentrating, and reduced functioning (Morgan et al., 2022). This diagnosis was considered because the patient identified stressors that may have contributed to emotional distress.

Reflections:

If the session were conducted again, more time would be used to complete a detailed psychosocial and safety assessment. Although the patient denied suicidal ideation, a structured suicide risk evaluation would strengthen clinical assessment and patient safety. Additional questions about sleep patterns, daily stressors, family relationships, and occupational concerns would help identify contributing factors to the depressive symptoms. Greater emphasis would also be placed on baseline measurement of symptom severity using the Patient Health Questionnaire-9 during the initial encounter. This screening tool provides objective data that supports diagnostic evaluation and monitoring of treatment progress. More discussion about coping strategies, stress management techniques, and available community support resources would also be included to improve the patient’s understanding of depression management.

If follow-up with the patient were possible, the visit would focus on evaluating response to treatment and overall functioning. Assessment would include changes in mood, sleep quality, appetite, concentration, and daily activity level since the previous visit. Improvement in depressive symptoms and increased participation in normal activities would suggest that the treatment plan is effective. Medication adherence and tolerance to sertraline 50 mg would also be reviewed, along with monitoring for possible side effects. If significant symptom improvement occurred, continuation of the current treatment approach would be appropriate. The next intervention would include reinforcing medication adherence, encouraging participation in psychotherapy, and continuing symptom monitoring during future visits.

Case Formulation and Treatment Plan:

The treatment plan focused on evidence-based management of major depressive disorder using pharmacologic therapy, psychotherapy, and supportive lifestyle interventions. Clinical practice guidelines recommend antidepressant medication as a first-line treatment for moderate depressive episodes because it improves mood symptoms, functioning, and overall quality of life (American Psychiatric Association, 2022). The patient presented with depressed mood, fatigue, sleep disturbance, reduced appetite, poor concentration, and loss of interest in daily activities, which support the use of antidepressant therapy. Treatment goals include reduction of depressive symptoms, improvement in daily functioning, restoration of sleep patterns, and prevention of symptom recurrence (Qaseem et al., 2023). The plan also included monitoring of symptom severity and safety concerns. Psychosocial support and mental health counseling were discussed to address emotional stressors contributing to depressive symptoms.

An FDA-approved psychopharmacologic agent selected for treatment was sertraline 50 mg taken orally once daily. Sertraline is a selective serotonin reuptake inhibitor that increases serotonin availability in the brain and improves mood regulation. Selective serotonin reuptake inhibitors are widely recommended as first-line medications because they are effective and generally well tolerated compared with other antidepressant classes (Qaseem et al., 2023). Sertraline was chosen because it is commonly used in the treatment of depressive disorders and has strong evidence supporting improvement in mood, sleep patterns, and emotional functioning. The patient received education regarding possible side effects such as nausea, headache, mild gastrointestinal discomfort, and sexual dysfunction. The importance of consistent medication use and monitoring for mood changes was discussed.

Alternative treatment options were also reviewed. Other selective serotonin reuptake inhibitors, such as escitalopram or fluoxetine, may be considered if the patient does not respond adequately to sertraline. Serotonin norepinephrine reuptake inhibitors such as venlafaxine or duloxetine may also be used in patients who continue to experience depressive symptoms. Psychotherapy is strongly supported in research as an effective treatment for depression (Qaseem et al., 2023). Cognitive behavioral therapy focuses on identifying negative thinking patterns and replacing them with healthier cognitive responses. Interpersonal therapy may also help patients improve relationships and manage stress. Lifestyle interventions such as regular physical activity, improved sleep habits, and structured daily routines were recommended because research shows that these interventions support mood improvement and emotional regulation.

The follow-up plan includes reassessment of depressive symptoms and evaluation of medication response. The patient will return for follow-up in four weeks to review symptom improvement and overall functioning. Depression severity will be reassessed using the Patient Health Questionnaire-9. The patient was advised to seek immediate medical attention if suicidal thoughts, worsening mood, or severe adverse medication reactions occur. A referral was recommended for psychotherapy with a licensed mental health therapist to provide cognitive behavioral therapy. Community support resources may also help improve coping skills and emotional support.

One social determinant of health relevant to this case is the social and community context. Healthy People 2030 identifies social support and community engagement as important influences on mental health outcomes. Limited social support may increase the risk of depression and reduce access to mental health care. A health promotion activity recommended for this patient includes participation in regular physical activity, such as walking or light exercise, several times each week to support mood improvement. A patient education strategy includes teaching the patient about recognizing early symptoms of depression and the importance of seeking mental health support when symptoms begin to worsen. Education helps reduce stigma and improves engagement in mental health treatment.

PRECEPTOR VERIFICATION:

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text revision). American Psychiatric Publishing.

Goncalves, W. S., Gherman, B. R., Abdo, C. H. N., Coutinho, E. S. F., Nardi, A. E., & Appolinario, J. C. (2023). Prevalence of sexual dysfunction in depressive and persistent depressive disorders: A systematic review and meta-analysis. International Journal of Impotence Research, 35(4), 340–349. https://doi.org/10.1038/s41443-022-00539-7

Morgan, M. A., Kelber, M. S., Bellanti, D. M., Beech, E. H., Boyd, C., Galloway, L., & Belsher, B. E. (2022). Outcomes and prognosis of adjustment disorder in adults: A systematic review. Journal of Psychiatric Research, 156, 498–510. https://doi.org/10.1016/j.jpsychires.2022.10.052

Qaseem, A., Owens, D. K., Etxeandia-Ikobaltzeta, I., Tufte, J., Cross Jr, J. T., Wilt, T. J., & Yost, J. (2023). Nonpharmacologic and pharmacologic treatments of adults in the acute phase of major depressive disorder: a living clinical guideline from the American College of Physicians. Annals of Internal Medicine, 176(2), 239-252. https://doi.org/10.7326/M22-2056

 

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Prac 6665 week 3 Assignment 2 Focused SOAP Note and Patient Case Presentation, Part 1

Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will document information about a patient that you examined during the last three weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.

 

Resources

Learning Resources

Required Readings

• Carlat, D. J. (2024). The psychiatric interview (5th ed.). Wolters Kluwer.
  • Section III. Interviewing for Diagnosis: The Psychiatric Review of Symptoms (Chapters 22–23)
  • Chapter 20 “How to Memorize the DSM-5-TR Criteria”
  • Chapter 35 “Writing Up the Results of the Interview”
  • Appendix A pages 294–300
  • Appendix B pages 301–316
• Lorberg, B., Davico, C., Martsenkovskyi, D., & Vitiello, B. (2019). Principles in using psychotropic medication in children and adolescents.Links to an external site. In J. M. Rey & A. Martin (Eds ), IACAPAP e-textbook of child and adolescent mental health (2019 ed., pp. 1–25). International Association for Child and Adolescent Psychiatry and Allied Professions. https://iacapap.org/_Resources/Persistent/45bdffb25befc353c9f61988e82105029504ab85/A.7-Psychopharmacology-2019.1.pdf
• MeditrekLinks to an external site.
  https://edu.meditrek.com/Default.html
  Note: Use this link to log into Meditrek to report your clinical hours and patient encounters.
• Document: Focused SOAP Note Template Download Focused SOAP Note Template(Word document)
• Document: Focused SOAP Note Exemplar Download Focused SOAP Note Exemplar(Word document)

Recommended

• Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.

 

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

To Prepare

• Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
• Select a patient of any age (either a child or an adult) that you examined during the last 3 weeks.
• Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.
  Please Note:
  • All SOAP notes must be signed, by your Preceptor. Note: Electronic signatures are not accepted.
  • When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of the completed assignment signed by your Preceptor.
  • You must submit your SOAP note using Turnitin. Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.
• Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record.
• Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
• Ensure that you have the appropriate lighting and equipment to record the presentation.

The Assignment

Record yourself presenting the complex case for your clinical patient.

Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video.

In your presentation:

• Dress professionally and present yourself in a professional manner.
• Display your photo ID at the start of the video when you introduce yourself.
• Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
• Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
• Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
• Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide:
  • Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
  • Objective: What observations did you make during the psychiatric assessment?
  • Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.
  • Plan: In your video, describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session?
  • In your written plan include all the above as well as include one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
  • Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.

By Day 7 of Week 3

Submit your Video and Focused SOAP Note Assignment. You must submit two files for the note, including a Word document and scanned pdf/images of completed assignment signed by your Preceptor.

submission information – Part 1: Video Submission

To submit your video response entry:

1. Click on Start Assignment near the top of the page.
2. Next, click Text Entry and then click the Embed Kaltura Media button.
3. Select your recorded video under My Media.
4. Check the box for the End-User License Agreement and select Submit Assignment for review.

submission information – Part 2: Focused SOAP Note Submission

To submit Part 2 of this Assignment, click on the following link:

• Week 3 Assignment 2, Part 2

 

Rubric

PRAC_6665_Week3_Assignment2_Pt1_Rubric

PRAC_6665_Week3_Assignment2_Pt1_Rubric
Criteria	Ratings	Pts
This criterion is linked to a Learning OutcomePhoto ID display and professional attire	5 to >0.0 ptsExcellentPhoto ID is displayed. The student is dressed professionally. 0 ptsFair 0 ptsGood 0 ptsPoorPhoto ID is not displayed. Student must remedy this before grade is posted. The student is not dressed professionally.	5 pts
This criterion is linked to a Learning OutcomeTime	5 to >0.0 ptsExcellentThe video does not exceed the 8-minute time limit. 0 ptsFair 0 ptsGood 0 ptsPoorThe video exceeds the 8-minute time limit. (Note: Information presented after 8 minutes will not be evaluated for grade inclusion.)	5 pts
This criterion is linked to a Learning OutcomeDiscuss Subjective data:• Chief complaint• History of present illness (HPI)• Medications• Psychotherapy or previous psychiatric diagnosis• Pertinent histories and/or ROS	10 to >8.0 ptsExcellentThe video accurately and concisely presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis. 8 to >7.0 ptsGoodThe video accurately presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis. 7 to >6.0 ptsFairThe video presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis, but is somewhat vague or contains minor inaccuracies. 6 to >0 ptsPoorThe video presents an incomplete, inaccurate, or unnecessarily detailed/verbose description of the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis. Or subjective documentation is missing.	10 pts
This criterion is linked to a Learning OutcomeDiscuss Objective data:• 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	10 to >8.0 ptsExcellentThe video accurately and concisely documents the patient’s physical exam for pertinent systems. Pertinent diagnostic tests and their results are documented, as applicable. 8 to >7.0 ptsGoodThe response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are documented, as applicable. 7 to >6.0 ptsFairDocumentation of the patient’s physical exam is somewhat vague or contains minor inaccuracies. Diagnostic tests and their results are documented but contain inaccuracies. 6 to >0 ptsPoorThe response provides incomplete, inaccurate, or unnecessarily detailed/verbose documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or objective documentation is missing.	10 pts
This criterion is linked to a Learning OutcomeDiscuss results of Assessment:• Results of the mental status examination• Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.	20 to >17.0 ptsExcellentThe video accurately documents the results of the mental status exam. Video presents at least three differentials in order of priority for a differential diagnosis of the patient, and a rationale for their selection. Response justifies the primary diagnosis and how it aligns with DSM-5 criteria. 17 to >15.0 ptsGoodThe video adequately documents the results of the mental status exam. Video presents three differentials for the patient and a rationale for their selection. Response adequately justifies the primary diagnosis and how it aligns with DSM-5 criteria. 15 to >13.0 ptsFairThe video presents the results of the mental status exam, with some vagueness or inaccuracy. Video presents three differentials for the patient and a rationale for their selection. Response somewhat vaguely justifies the primary diagnosis and how it aligns with DSM-5 criteria. 13 to >0 ptsPoorThe response provides an incomplete, inaccurate, or unnecessarily detailed/verbose description of the results of the mental status exam and explanation of the differential diagnoses. Or assessment documentation is missing.	20 pts
This criterion is linked to a Learning OutcomeDiscuss treatment Plan:• A treatment plan for the patient that addresses chosen FDA-approved psychopharmacologic agents and includes alternative treatments available and supported by valid research. The treatment plan includes rationales, a plan for follow-up parameters, and referrals. The discussion includes one social determinant of health according to the HealthyPeople 2030, one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health.	20 to >17.0 ptsExcellentThe video clearly and concisely outlines an evidence-based treatment plan for the patient that addresses FDA-approved psychopharmacologic agents and includes alternative treatments and rationale supported by valid research. … Discussion includes a clear and concise follow-up plan and parameters…. The discussion includes a clear and concise referral plan. … The paper discussion contains all 3 elements from the assignment directions including a discussion demonstrating critical thinking of the case related to the HealthyPeople 2030 social health determinates. Clearly and concisely relates discussion to the psychiatric and mental health field. 17 to >15.0 ptsGoodThe video clearly outlines an appropriate treatment plan without evidence-based discussion for the patient that addresses FDA-approved psychopharmacologic agents and includes alternative treatments and rationale supported by vague or questionable research. … Discussion includes a clear follow-up plan and parameters…. The discussion includes a clear referral plan…. The paper discussion contains 2 of the elements from the assignment directions with one being a basic discussion of the case related to the HealthyPeople 2030 social health determinates. Clearly relates discussion to the psychiatric and mental health field. 15 to >13.0 ptsFairThe response somewhat vaguely or inaccurately outlines a treatment plan for the patient that addresses psychopharmacologic agents without discussion of FDA approval and includes vague or inaccurate alternative treatments with little rationale discussed. … The discussion is somewhat vague or inaccurate regarding the follow-up plan and parameters…. The discussion is somewhat vague or inaccurate regarding a referral plan. … The paper discussion contains 1 of the required elements from the assignment directions which is the HealthyPeople 2030 social health determinates…. Somewhat vaguely or inaccurately relates discussion to the psychiatric and mental health field. 13 to >0 ptsPoorThe response does not address the treatment plan or the treatment plan is not appropriate for the assessment and the diagnosis. There is no mention of FDA approval for treatment choices or no research supported discussion. Alternative treatment discussion is missing. … Rationales for treatments are missing. … There is no discussion for follow-up and parameters. … There is no discussion of a referral plan. … The paper discussion is missing discussion relating to the psychiatric and mental health field or relates discussion to another specialty realm including medical co-morbidity illnesses.	20 pts
This criterion is linked to a Learning OutcomeReflect on this case. Discuss what you learned and what you might do differently.	5 to >4.0 ptsExcellentReflections are thorough, thoughtful, and demonstrate critical thinking. 4 to >3.5 ptsGoodReflections demonstrate critical thinking. 3.5 to >3.0 ptsFairReflections are somewhat general or do not demonstrate critical thinking. 3 to >0 ptsPoorReflections are incomplete, inaccurate, or missing.	5 pts
This criterion is linked to a Learning OutcomePresentation style	5 to >4.0 ptsExcellentPresentation style is exceptionally clear, professional, and focused. 4 to >3.5 ptsGoodPresentation style is clear, professional, and focused. 3.5 to >3.0 ptsFairPresentation style is mostly clear, professional, and focused 3 to >0 ptsPoorPresentation style is unclear, unprofessional, and/or unfocused.	5 pts

Total Points: 80