Description
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
3 / 6 pts
Total Points: 76
Unformatted Attachment Preview
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
2 pts
1/
complaint
2
Chief Complaints identifies
view longer description
pts
reason for the visit
1 pts
Chief Complaint does not
identify reason for the visit
0 pts
No Chief Complaint
History of Present Illness – Symptom analysis
4 pts
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
2/
4
Full symptoms assessment for
each complaint
4 points
pts
Clinical Journal Rubric
Criteria
Ratings
view longer description
3 pts
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
Psychiatric Review of Symptoms (Psych ROS) –
4 pts
Asks about symptoms for Depression, Mania,
GAD, Panic, OCD, Trauma, Social anxiety,
phobias, Hallucinations, Delusions, ADHD,
4/
4
Completes a full Psych ROS
4 points
disordered eating
3 pts
view longer description
Addresses most of Psych ROS
(has 7 or more components)
3 points
2 pts
pts
Clinical Journal Rubric
Criteria
Ratings
Pts
Addresses partial Psych ROS
(has less than 7 components)
2-1 points
0 pts
No Psych ROS
0 points
Safety Assessment – Includes suicidal
3 pts
ideation/homicidal, access to weapons, past
suicidal/homicidal attempts, other risk factors
view longer description
2/
3
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
pts
Clinical Journal Rubric
Criteria
Ratings
Pts
0 Points
Substance Abuse history – Includes detail of
3 pts
each substance used, last used and past
interventions (rehab, groups)
view longer description
2/
3
Detailed substance abuse history
pts
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
Past Psychiatric History – Includes past therapy, 3 pts
3/
psychiatry, hospitalizations, past psychiatric
3
medications
view longer description
Detailed Past Psychiatric History
3 points
pts
Clinical Journal Rubric
Criteria
Ratings
Pts
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
Past Medical History – Includes last PE, current 3 pts
3/
medical conditions, hx of surgeries, current non-
3
psychiatric medications
Has detailed Past Medical
History
view longer description
3 Points
2 pts
Past Medical History is mostly
complete
2 points
pts
Clinical Journal Rubric
Criteria
Ratings
Pts
1.2 pts
Past Medical History needs
improvement
1 point
0 pts
No Past Medical History
0 Points
Medical Review of Systems – Includes
3 pts
Constitution, EENT, Cardiovascular,
Respiratory, Gastrointestinal, Genitourinary,
Musculoskeletal, Integumentary, Endocrine,
3/
3
Has >90% of Medical Review of
Systems accurately documented
Neurological, Immunological, Reproductive, and 3 points
Hematological Systems
2 pts
view longer description
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
pts
Clinical Journal Rubric
Criteria
Ratings
Pts
0 pts
No Family History
0 Points
Family History – Includes family psychiatric and 3 pts
3/
pertinent medical history, family substance
3
abuse, family legal history, family SI/HI history
view longer description
Has complete Family history
pts
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
Developmental History – Includes childhood
3 pts
development, childhood home atmosphere,
educational history, employment history
3/
3
Has complete Developmental
pts
Clinical Journal Rubric
Criteria
Ratings
view longer description
History
Pts
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
Social History – Includes relationship (SO,
3 pts
Family), current supports, spirituality, hobbies,
future plans
view longer description
3/
3
Has full Social History
3 Points
2 pts
Has most of Social History
pts
Clinical Journal Rubric
Criteria
Ratings
Pts
2 points
1 pts
Social History needs
improvement
1 Point
0 pts
No Social History
0 points
PE & Objective Information Includes VS,
2 pts
Wt/Ht, BMI, Labs and any other pertinent
information (i.e. screenings if present) If labs
are not available, documents what labs they
2/
2
Full PE and labs documented
pts
2 points
would like to see for this patient
1 pts
view longer description
Partial PE
1 Points
0 pts
No PE or Labs
0 Points
Mental Status Examination (MSE) – Includes
Appearance, Behavior, Attitude, Speech, Affect,
8 pts
6/
8
Clinical Journal Rubric
Criteria
Ratings
Pts
Mood, Thought Process & Content, Attention,
Complete components of MSE
pts
Memory, Orientation, Memory, Abstraction,
accurately
Intelligence, Insight, Judgment
8 Points
view longer description
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
Diagnostic Formulation – The diagnosis(es) flow 18 pts
11
from the histories and exam. Each diagnosis has
/
>90% diagnosis(es) are
Clinical Journal Rubric
Criteria
Ratings
Pts
rationale and supporting evidence taken from
addressed in a clear and
18
the histories/Exam
organized manner, including
pts
rationale for each Dx that is
view longer description
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
Clinical Journal Rubric
Criteria
Ratings
Pts
0 pts
No Diagnostic Formunlation
0 Points
Differential Diagnosis(es) – Includes possible
10 pts
diagnosis(es) identified in histories but missing
criteria to rule in completely, gives rationale for
each DDx
10
All Differential Diagnosis(es)
identified from the history and
rationale is documented in a
view longer description
4/
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
pts
Clinical Journal Rubric
Criteria
Ratings
Pts
No DDx identified
0 Points
Problem List – Includes the ICD-10 and DSM
2 pts
diagnostic codes for all Dx, DDx and medical dx
identified
1/
2
All codes are listed for identified
pts
Dx & DDx
view longer description
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
Treatment Planning: Pharmacological –
4 pts
Identifies appropriate medication(s) for
identified Diagnosis(es); Written as a script,
including medication name, dose, sig, refills
4/
4
Has appropriate use of
pharmacological intervention
written in the form of script
pts
Clinical Journal Rubric
Criteria
Ratings
view longer description
4 Points
Pts
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
Treatment Planning: Non-pharmacological –
4 pts
Includes referrals, therapies, other interventions
(i.e. exercise, support groups)
4
Identifies comprehensive list of
non-pharmacological
view longer description
4/
interventions for pt need
4 Points
pts
Clinical Journal Rubric
Criteria
Ratings
Pts
1 pts
Identified Partial list of nonpharmacological interventions
for pt need
3-1 Points
0 pts
No Non-pharmacological
Interventions identified
0 Points
Treatment Planning: Education – Includes
4 pts
disease prognosis, medication education (side
effects, administration, off label use), safety
planning, nutrition, sleep hygiene, how to reach
4/
4
Addresses all educational needs
4 Points
provider….
2 pts
view longer description
Addresses the majority of
educational needs
3-2 Points
1 pts
Educational needs addressed but
needs improvement
1 Point
pts
Clinical Journal Rubric
Criteria
Ratings
Pts
0 pts
No educational needs addressed
0 Points
Psychopharmacology Rationale (Psychiatric
5 pts
Meds Only) – Thorough explanation that
includes medication class, mechanism of action,
side effects, black box warnings,
contraindications. Also includes rationale as to
5/
5
Includes all elements listed and
full rationale for medication(s)
chosen
why each medication was chosen for this patient. 5 Points
Uses high quality evidence based resources to
support medication choices
4 pts
view longer description
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
pts
Clinical Journal Rubric
Criteria
Ratings
Pts
rationale provided
0 Points
Reflection and Supervision Log – Reflection
3 pts
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
3/
3
Includes both Weekly Reflection
that includes progress toward
clinical objectives and
Supervision Log
3 Points
journal and a summary of what was discussed
with your preceptor
2 pts
view longer description
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
pts
Clinical Journal Rubric
Criteria
Ratings
Pts
Clinical Supervision Log
0 Points
Overall Note – Note is organized, succinct, clear
6 pts
understanding of subjective and objective data.
Grammar and punctuation are correct. If
references used, APA format is correct
6
Note is organized, succinct, clear
understanding of subjective and
objective data. Grammar and
view longer description
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
Total Points: 76
3/
pts
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
4 / 4 pts
Clinical Journal Rubric
Criteria
Ratings
Pts
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
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
2 / 3 pts
Clinical Journal Rubric
Criteria
Ratings
Pts
0 pts
No substance abuse
history
0 Points
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 nonpsychiatric 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
Clinical Journal Rubric
Criteria
Ratings
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
3 pts
Has complete
Developmental
3 / 3 pts
Clinical Journal Rubric
Criteria
Ratings
view longer description
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
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
2 / 2 pts
Clinical Journal Rubric
Criteria
Ratings
Pts
No PE or Labs
0 Points
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
11 / 18
pts
Clinical Journal Rubric
Criteria
Ratings
Pts
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
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
4 / 10
pts
Clinical Journal Rubric
Criteria
Ratings
Pts
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
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
4 / 4 pts
Clinical Journal Rubric
Criteria
Ratings
Pts
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
Treatment Planning: Non-pharmacological Includes referrals, therapies, other interventions
(i.e. exercise, support groups)
view longer description
4 pts
Identifies
comprehensive list
of nonpharmacological
interventions for pt
need
4 Points
1 pts
Identified Partial list
of nonpharmacological
interventions for pt
need
3-1 Points
0 pts
No Nonpharmacological
Interventions
identified
0 Points
4 / 4 pts
Treatment Planning: Education – Includes disease
prognosis, medication education (side effects,
administration, off label use), safety planning,
4 pts
Addresses all
educational needs
4 / 4 pts
Clinical Journal Rubric
Criteria
Ratings
nutrition, sleep hygiene, how to reach provider….
view longer description
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
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
Pts
5 / 5 pts
Clinical Journal Rubric
Criteria
Ratings
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
3 / 6 pts
Clinical Journal Rubric
Criteria
Ratings
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
Total Points: 76
Pts
Comprehensive Psychiatric Evaluation
Journal #1
****
1
Practicum Clinical Journal #1
Date: October 5, 2023
Time started: 10:00 a.m.-11:30 a.m.
Site: Integrated Healthcare Services Behavioral Health/IHS BH
Level of Supervision: Primary (>50%)
Identifying Data
Patient Initials: AD
Age: 35 years
Gender: Female
Marital Status: Married
Religion: Unknown
Occupation: Office Manager
Language Spoken: English
Living Arrangements: Lives with spouse and two children in a condominium
Source and Reliability
Accompanied By: None; patient presented alone
Source of Information: Patient
Chief Complaint (CC):”Constant worrying and fear that something terrible is going to happen.”
History of Present Illness
AD states that for the past six months, she has been experiencing excessive worrying,
restlessness, and a constant sense of unease. She reports that these symptoms have been
progressively getting worse and have become increasingly intrusive, significantly affecting her
daily life and causing sleep disturbances. According to AD, the quality of her anxiety feels like
2
an overwhelming sense of dread, and she describes it as a constant ‘knot in her stomach.’ She
rates the severity of her symptoms as 9 out of 10, emphasizing the profound impact on her
overall well-being. AD mentions that these symptoms have been persistent for the past six
months, indicating their chronic nature. She further reports that her anxiety seems unpredictable,
lacking any specific timing or context-dependent trigger, and it occurs even when there are no
apparent stressors. AD states that while she briefly finds relief through mindfulness exercises,
her anxiety quickly returns, and there are no consistent modifying factors that alleviate her
distress. Additionally, she reports experiencing associated physical manifestations, including
muscle tension, headaches, and gastrointestinal discomfort, which further contribute to her
distress.
Psychiatric Review of Symptoms (Psych ROS)
Depression: AD reports no feelings of depression, stating that she generally does not experience
prolonged periods of sadness or hopelessness. However, she states that she feels tired, has
trouble sleeping, and sometimes has low interest in doing things. Her PHQ score was 9.
Mania: AD states that she has not experienced any symptoms of mania, such as elevated mood,
excessive energy, or impulsivity. AD states that she is not easily irritable and denies any negative
thoughts. Her MDQ score was 4.
GAD (Generalized Anxiety Disorder): AD emphasizes that her primary concern leading to the
visit is her overwhelming and persistent anxiety, which she describes as a constant state of worry
and unease. She also adds that she is easily fatigued, irritable, difficulty in concentrating and
sleeps about 4 hours then wakes up continuously. The GAD-7 score for AD is 14, which is
moderate anxiety.
3
Panic: AD reports occasional panic attacks, describing them as sudden and intense episodes of
extreme fear, palpitations, and shortness of breath. She mentions that these episodes can be
distressing and disruptive.
OCD (Obsessive-Compulsive Disorder): AD states that she has not been troubled by
obsessions or compelled to perform repetitive behaviors characteristic of OCD.
Trauma: AD firmly denies a history of trauma, indicating that she has not experienced any
significant traumatic events in her life.
Social Anxiety: AD does not mention specific social anxiety symptoms, suggesting that her
anxiety is not limited to social situations but is more generalized.
Phobias: AD does not identify any specific phobias or intense fears that trigger her anxiety.
Hallucinations: AD states that she has not experienced any hallucinations, indicating that she
does not perceive things that are not present.
Delusions: AD reports no delusions, affirming that she maintains a firm grip on reality.
ADHD (Attention-Deficit/Hyperactivity Disorder): AD mentions that she has not noticed
symptoms associated with ADHD, such as inattention, hyperactivity, or impulsivity.
Disordered Eating: AD states that she does not engage in any disordered eating behaviors, such
as binge eating, purging, or restrictive eating patterns.
Safety Assessment
Suicidal Ideation/Homicidal: AD firmly denies experiencing any current or past thoughts of
harming herself or others. She emphasizes that she has never entertained the idea of suicide or
homicidal actions throughout her life.
4
Access to Weapons: AD states that there is no access to any weapons within her household. She
clarifies that her living environment is free from any firearms, sharp objects, or potentially
harmful items.
Past Suicidal/Homicidal Attempts: AD states that she has never made any suicidal or
homicidal attempts in the past. She reports that her history is void of any such actions,
reinforcing her commitment to her own safety and the safety of others.
Other Risk Factors: AD indicates that there are no other immediate risk factors of concern. She
does not mention any circumstances, relationships, or situations that could pose a risk to her
mental or emotional well-being.
Substance Abuse History
Alcohol: AD reports her alcohol consumption habits, describing occasional use typically limited
to social occasions. She clarifies that her alcohol intake is moderate and does not result in
excessive or problematic drinking.
Tobacco: AD denies any use of tobacco products, highlighting her non-smoker status.
Illicit Drugs: AD states that she has never engaged in the use of illicit drugs. She emphasizes her
commitment to a drug-free lifestyle.
Prescription Medications: AD indicates that she is currently taking oral contraceptives solely
for birth control purposes. She emphasizes that this medication is prescribed and used in
accordance with medical guidelines.
Past Psychiatric History: AD asserts that she has no prior history of psychiatric treatment or
medications. She states that her visit marks her first engagement with psychiatric evaluation and
intervention, implying that her current symptoms of anxiety are her first encounter with such
mental health concerns.
5
Past Medical History
Insurance and Providers: AD is currently insured through XYZ Insurance. She states that she
had her comprehensive body check-up three years ago.
Medical History: AD reports that her primary care provider is Dr. Smith, and her psychiatrist is
Dr. Johnson. She states that she is currently under no medication. She indicated that yesterday
she took 400mg ibuprofen for her headache. She states that she took the medication once and the
headache subsided.
Seizure History:AD reports no history of seizures or epilepsy. She has never experienced
seizures, and there is no family history of seizure disorders.
Last Physical Examination: AD affirms that she underwent her most recent physical
examination within the past year, which was part of her routine check-up. This indicates her
commitment to regular health maintenance and suggests an active interest in monitoring her
physical well-being.
Current Medical Conditions:AD clearly states that she is not currently dealing with any
medical conditions. Her self-report is indicative of a generally healthy physical state, devoid of
any ongoing illnesses or health concerns.
OTC/Supplements: 400mg Ibuprofen yesterday for her headache. Denies being on any
supplements.
History of Surgeries: AD provides insight into her surgical history by mentioning that she
underwent an appendectomy at the age of 18. This information helps establish a comprehensive
medical background, highlighting a past surgical procedure that is relevant to her current health
status.
6
Allergies: She states that she does not react to any drug or food. She adds that there are no
known environmental allergies.
Current Non-Psychiatric Medications: AD confirms that she is currently taking oral
contraceptives, specifically a combination of ethinyl estradiol and norgestimate, on a daily basis.
This medication, typically prescribed for birth control, is mentioned explicitly, demonstrating her
awareness of and adherence to prescribed non-psychiatric medications.
Medical Review of Systems
Constitutional: AD reports the absence of fever, weight loss, or fatigue. These observations are
essential in ruling out systemic illnesses that might present with these constitutional symptoms.
Her report suggests an overall sense of well-being in terms of general health.
HEENT (Head, Eyes, Ears, Nose, Throat):AD reports that there are no visual or auditory
disturbances reported by AD. This indicates normal sensory functions in her eyes and ears,
which is vital for her daily functioning and quality of life.
Cardiovascular: AD states that she has not experienced chest pain or palpitations. These
symptoms can be indicative of cardiac issues, and their absence in her report is reassuring
regarding her heart health.
Respiratory: She denies shortness of breath or cough. These symptoms are essential indicators
of respiratory conditions. The absence of such symptoms suggests that AD’s respiratory system
is functioning normally.
Gastrointestinal: AD mentions occasional abdominal discomfort attributed to anxiety. This
observation is significant, as it aligns with her anxiety disorder diagnosis. Anxiety can manifest
with gastrointestinal symptoms, and her disclosure provides context for her condition.
7
Genitourinary: AD does not report any urinary symptoms. This information suggests the
absence of urinary tract problems or related issues.
Musculoskeletal: She acknowledges experiencing muscle tension associated with anxiety. This
symptom is consistent with her generalized anxiety disorder (GAD) diagnosis and is a common
physical manifestation of anxiety.
Integumentary: AD reports no skin issues. This is reassuring, as skin problems can be indicative
of various dermatological conditions, which are not presently a concern for her.
Endocrine: She does not mention any symptoms suggestive of hormonal imbalance. This is
pertinent in ruling out endocrine disorders, which could affect various bodily functions.
Neurologic: AD specifically denies seizures, headaches associated with anxiety, or neurological
deficits. Her clarification regarding headaches underscores their relation to her anxiety and not a
separate neurological issue.
Immunological: She states that she has no history of autoimmune disorders. This information is
significant in assessing her immune system health.
Reproductive: AD notes regular menstrual cycles and no gynecological complaints. This
information indicates normal reproductive and gynecological health.
Hematologic: She reports no bleeding or clotting disorders. Hematological issue
