Write a Psychiatric evaluation on a 61-year-old African American male with schizophrenia.
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Write a Psychiatric evaluation on a 61-year-old African American male with schizophrenia. Please see the Rubric below: This table lists criteria and criteria group names in the first column. The first row lists level names and includes scores if the rubric uses a numeric scoring method. You can give feedback on each criterion by tabbing to the add feedback buttons in the table. Criteria Excellent Good Acceptable Unacceptable Criterion Score Demographic Data 5 points Includes identifying information including initials, age, gender, ethnicity. Primary source of information and reliability as well as reason for referral and patient understanding of referral are clear. 3 points Includes identifying information but leaves out some key elements. Primary source of information and reliability as well as reason for referral and patient understanding of referral are noted. 1 point Includes minimal identifying information. Primary source of information and reliability as well as reason for referral and patient understanding of referral are not included or are unclear. 0 points Does not adequately convey topic. Missing all or most key elements. Score of Demographic Data,/ 5 Subjective Data History of Present Illness (HPI) 20 points CC is clear, concise and verbatim from pt. HPI is thorough yet concise and provides a chronological account of symptoms and contextual factors that are sufficiently descriptive (oldcarts) to validate Dx per DSM-5 criteria. All pertinent negatives are included. A longitudinal course of illness is clear. Current psychiatric medications and response are included. 14 points CC is clear, concise and verbatim from pt. HPI is thorough yet concise and provides a chronological account of symptoms with some contextual factors that are sufficiently descriptive (oldcarts) to validate Dx per DSM-5 criteria. Pertinent negatives are included. A longitudinal course of illness is appreciable. Current psychiatric medications and response are included. 8 points CC is clear. HPI provides an account of symptoms that are descriptive, nonchronological, without context, and do not clearly validate Dx per DSM-5 criteria. Few pertinent negatives are included. A longitudinal course of illness is unclear. Current medications are included. 0 points CC is not recorded. HPI does not reflect a chronological account of symptoms that are sufficiently descriptive to validate Dx per DSM-5 criteria. Pertinent negatives are not included. The longitudinal course of illness is nonexistent. Score of Subjective Data History of Present Illness (HPI),/ 20 Past Psychiatric History 5 points PPH contains all previous treatment including previous Dx, hospitalizations, outpatient treatments, suicide attempts, self-harm, and previous medications with detailed trial and response history. Pertinent negatives are also included. 3 points PPH contains most data regarding previous treatment including previous Dx, hospitalizations, outpatient treatments, suicide attempts, self-harm, and previous medications with detailed trial and response history. Pertinent negatives are also included. 1 point PPH contains sparse data regarding previous treatment including previous Dx, hospitalizations, outpatient treatments, suicide attempts, self-harm. Previous medication history is sparse and without detailed trial and response history. Pertinent negatives are unclear. 0 points PPH contains no previous treatment Hx including previous Dx, hospitalizations, outpatient treatments, suicide attempts, self-harm, nor is there descriptions of previous medications with detailed trial and response history. Pertinent negatives are not included. Score of Past Psychiatric History,/ 5 Substance Use History 5 points Complete substance use history is documented. Pertinent negatives are clear evidenced by appropriate pt. responses ie. “denies”. Age of onset, duration, frequency/pattern of use, route of administration, last use, consequences of use. Not limited to illicit substances. Inclusive of addictive behavioral patterns. 3 points Complete substance use history is documented. Most pertinent negatives are documented. Age of onset, duration, frequency/pattern of use, route of administration, last use, consequences of use. Not limited to illicit substances. Inclusive of addictive behavioral patterns. 1 point Substance use history is documented but data is sparse. Pertinent negatives are unclear. Age of onset, duration, frequency/pattern of use, route of administration, last use, consequences of use are not all included. Not limited to illicit substances. Review of addictive behavioral patterns absent. 0 points Substance use history is not documented. No inclusion of addictive behavioral patterns. Score of Substance Use History,/ 5 Past Medical History and Review of Systems (ROS) 5 points Medical history includes previous and current medical problems, surgeries, and allergies. ROS is germane to the presenting psychiatric problems and is free from objective assessment data ie. “lungs clear” “BS present”. 3 points Medical history includes previous and current medical problems, surgeries, and allergies. ROS is germane to the presenting psychiatric problems but is not free from objective assessment data ie. “lungs clear” “BS present” 1 point Medical history includes previous and current medical problems, surgeries, and allergies. ROS may be extraneous or incomplete for the presenting psychiatric problems and is not free from objective assessment data ie. “lungs clear” “BS present” 0 points Medical history is incomplete or absent. ROS is not complete or is not free from objective assessment data ie. “lungs clear” “BS present” Score of Past Medical History and Review of Systems (ROS),/ 5 Family History Psychosocial and Developmental History 10 points Family Hx includes identified relational status with current or historical psych illness, treatments, responses, suicides, or self-harm. Indication if biologically related. Dev’t Hx includes info regarding family of origin, siblings, birth order, family dynamics, relational patterns and status, educational, employment, abuse, spirituality, legal, military. Dev’t milestones for child & adolescents are included 7 points Family Hx includes current or historical psych illness without clear identification of relation, but does include treatments, responses, suicides, or self-harm. Dev’t Hx includes most info regarding family of origin, siblings, birth order, family dynamics, relational patterns and status, educational, employment, abuse, spirituality, legal, military. Dev’t milestones for child & adolescents are included 3 points Family Hx includes some of the identified relational status with current or historical psych illness, treatments, responses, suicides, or self-harm. No indication if biologically related. Dev’t Hx includes minimal info regarding family of origin, siblings, birth order, family dynamics, relational patterns and status, educational, employment, abuse, spirituality, legal, military. Few dev’t milestones for child & adolescents are included 0 points Family Hx is minimal or nonexistent and does not include identified relational status with current or historical psych illness, treatments, responses, suicides, or self-harm. Dev’t Hx minimally or does not include info regarding family of origin, siblings, birth order, family dynamics, relational patterns and status, educational, employment, abuse, spirituality, legal, military. Dev’t milestones for child & adolescents Score of Family History Psychosocial and Developmental History,/ 10 Objective Data Mental Status Exam Physical Exam (as appropriate) vital signs, height, weight, labs or other relevant 15 points MSE contains all elements as outlined in addendum.. Is in narrative form and effectively and vividly describes the patient’s presentation. Concrete examples of all assessment results are included ie. “able to correctly interpret 2/3 simple proverbs” to validate documentation of “abstract thought intact”. 10 points MSE contains all elements as outlined in addendum.. Is in narrative form and effectively and vividly describes the patient’s presentation. Concrete examples of all assessment results are included ie. “able to correctly interpret 2/3 simple proverbs” to validate documentation of “abstract thought intact”. 5 points MSE contains all elements as outlined in addendum.. Is in narrative form and effectively and vividly describes the patient’s presentation. Concrete examples of all assessment results are included ie. “able to correctly interpret 2/3 simple proverbs” to validate documentation of “abstract thought intact”. 0 points MSE missing most elements. Physical exam not documented Score of Objective Data Mental Status Exam Physical Exam (as appropriate) vital signs, height, weight, labs or other relevant,/ 15 Assessment 10 points Differential is pertinent to S&S, formulation contains evidence of critical thought and subject knowledge, and reasonable diagnoses are made per DSM-5. Clearly met criteria for diagnoses tendered are explicit in the HPI description and substantiated with the MSE. 7 points Differential is pertinent to S&S, formulation contains evidence of critical thought and subject knowledge, and reasonable diagnoses are made per DSM-5. Clearly met criteria for diagnoses tendered are explicit in the HPI description and substantiated with the MSE. 3 points Differential is impertinent to S&S, formulation appears rudimentary and vague. Diagnoses are made per DSM-5 but are marginally reasonable. Criteria for diagnoses tendered are not explicit in the HPI description or substantiated with the MSE. 0 points Differential is impertinent to S&S or absent. Formulation does not support nor clearly outline thought process of diagnoses. Diagnoses tendered are not supported by criteria in the HPI description or substantiated with the MSE. Score of Assessment,/ 10 Plan 15 points Evidence-based treatment plan is presented with detailed rationales. Level of detail reflects the student’s ability to choose treatments based not only on FDA approval or current evidence but also the nuances and unique characteristics of each. Treatment plan is holistic and comprehensive. There is strong evidence of the student’s synthesis of information and critical thought. 10 points Evidence-based treatment plan is presented with rationales. Level of detail reflects the student’s moderate ability to choose treatments based not only on FDA approval or current evidence but also the nuances and unique characteristics of each. Treatment plan is holistic and comprehensive. There is some evidence of the student’s synthesis of information and critical thought. 5 points Evidence-based treatment plan is presented with minimal rationales. Rationales reflect the student’s marginal ability to choose treatments based not only on FDA approval or current evidence but also the nuances and unique characteristics of each. Treatment plan is reasonable but lacks comprehensiveness. There is minimal evidence of synthesis of information and critical thought. 0 points Treatment plan is presented without sound rationales. There is no evidence of synthesis of information or critical thought. Score of Plan,/ 15 Writing, Support, APA 5 points The format is consistent with the example provided in the course. Strong, recent (5-7 years), scholarly, peer- reviewed support of topics. No grammar, spelling, and punctuation errors. Writing mechanics are consistent with formal scholarly work. No errors in APA style based upon the required APA manuals listed on the course syllabi. 3 points The format is fairly consistent with the example provided in the course. Clear, recent (5-7 years), scholarly, peer- reviewed support of topics. Minimal grammar, spelling, and punctuation errors. Writing mechanics include minimal awkward or unclear passages but are consistent with formal scholarly work. Minimal errors in APA style manuals listed on the course syllabi. 1 point The format is marginally consistent with the example provided in the course. Limited recent (5-7 years), scholarly, peer- reviewed support of topics. Occasional spelling, grammar, and punctuation errors detracting from the assignment. Writing mechanics include awkward or unclear passages and informal tone not always consistent with formal scholarly work. Occasional errors in APA style based upon the required APA manuals listed on the course syllabi. 0 points The format is not consistent with the example provided in the course. No recent, scholarly, peer- reviewed support of topic. Substantial grammar, spelling, and punctuation errors detracting from the assignment. Writing mechanics include many awkward or unclear passages and informal tone not consistent with formal scholarly work. Substantial errors in APA style based upon the required APA manuals listed on the course syllabi.
