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.

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

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

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.

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