Assignment task: Realistic Treatment Plan
For this assignment, you will develop a realistic clinical case presentation. Use PowerPoint to create the slides for your presentation. All information must be included in the actual slides
Content Requirements:
You will create a PowerPoint presentation with a realistic case study and include appropriate and pertinent clinical information based on the DSM5-TR and current US clinical guidelines to support the case:
1. Subjective data:
Chief Complaint
- Includes a direct quote from patient about presenting problem
Demographics
- Begins with patient initials, age, race, ethnicity, and gender (5 demographics)
History of the Present Illness (HPI) includes the presenting problem and the 8 dimensions of the problem. See an example of the correct way to document the psychiatric HPI
- Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS - Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)
Review of Systems (ROS)
- Includes a minimum of 3 assessments for each body system, assesses at least 9 body systems directed to chief complaint, AND uses the words "admits" and "denies"
2. Objective data:
Current Medications:
- Includes a list of all of the patient reported psychiatric and medical medications and the diagnosis for the medication (including name, dose, route, frequency)
Allergies:
- Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)
Past medical history:
- Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current
- Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), year of diagnosis and
Family psychiatric history:
- Includes an assessment of at least 6 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder and history of suicidal attempts
Social history:
- Distinguished Includes all 11 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation.
Labs and screening tools:
- Includes a list of the labs, diagnostic tests, or screening tools that should be completed for identified patient that are based on the US clinical guidelines OR acknowledges no labs/diagnostic tests are recommended.
Vital signs:
- Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)
Mental status exam:
- Includes all 10 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with detailed descriptions for each area
3. Assessment:
Primary Diagnosis - DSM5 only
- Includes a clear outline of the accurate principal diagnosis based on DSM5 or DSM5-TR criteria
Differential diagnosis - DSM5 only
- Includes at least 2 differential diagnoses for the principal diagnosis
4. Plan:
Pharmacologic treatment plan
- Includes a detailed pharmacologic and non pharmacological treatment plan for each of the diagnoses listed under "assessment". The plan includes ALL of the following: drug/vitamin/herbal name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. For non-pharmacological treatment, includes: treatment name, frequency, duration. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.
Non-pharmacologic treatment plan
Follow up plan
- Provides a detailed list of medical and other interdisciplinary referrals or documents NO REFERRAL ADVISED AT THIS TIME. Includes a timeline for follow up appointments.
5. Other:
o Incorporation of current US clinical guidelines
o Integration of research articles
o Role of the nurse practitioner
Submission Instructions:
o The presentation should consist of 10-15 slides.
o Incorporate a minimum of 6 current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work. Journal articles should be referenced according to the current APA style (the online library has an abbreviated version of the APA Manual).