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
18 (18%) – 20 (20%)
The response thoroughly 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.
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.
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 inaccuracies.
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:
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.
16 (16%) – 17 (17%)
The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.
14 (14%) – 15 (15%)
Documentation of the patient’s physical exam is somewhat vague or contains minor inaccuracies. Diagnostic tests and their results are documented but contain minor inaccuracies.
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:
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 dif">
| Excellent | Good | Fair | Poor | |
|---|---|---|---|---|
| Create documentation in the Comprehensive Psychiatric Evaluation Template about the patient you selected.
In the Subjective section, provide: |
18 (18%) – 20 (20%) The response thoroughly 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. |
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. |
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 inaccuracies. |
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. |
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. |
16 (16%) – 17 (17%) The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented. |
14 (14%) – 15 (15%) Documentation of the patient’s physical exam is somewhat vague or contains minor inaccuracies. Diagnostic tests and their results are documented but contain minor inaccuracies. |
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 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. |
23 (23%) – 25 (25%) The response thoroughly and accurately documents the results of the mental status exam. Response lists at least thre
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