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Comprehensive Case Study Layout
COMPREHENSIVE CASE TEMPLATE STUDY PART TWO.
Part two can be used on all populations
Don’t forget the written prescription on a separate piece of paper
Including the information listed in the rubric for each section is not enough to earn all the available points
Comprehensive Case Study Layout TIPS
The student is required to develop each section to show critical thinking skills moving the student toward the diagnosis and plan for the patient through a thorough discussion of conclusions drawn based on patient presentation as well as discussion of clinical decisions and planning. Furthermore, the development of the sections needs to show continuity between the sections and the diagnosis and plan at the end. Faculty who reads your case study should be able to see your thought processes while you are developing each section, see where you are heading with your diagnosis, and plan before arriving at them.
Rubric
Comprehensive Case Study Rubric PART TWO
Comprehensive Case Study Rubric PART TWO
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeDifferentials
Differentials: Five differential diagnoses including pertinent patient presentation/symptoms that should be considered and must be plausible to match the patient presentation. The student should write in detail WHY they thought the patient met this criterion using the previous information presented in part one and how the diagnosis was ruled out. The final diagnosis should NOT be included in the differential.
30 to >26.99 pts
Meets or EAC*
Differential diagnoses are plausible from the information in the previous sections, the student fully explains on each differential why they thought they were plausible, how the patient met the criteria and why they ruled them out, there may or may not be some errors
26.99 to >23.99 pts
Acceptable
Differential diagnoses are mostly plausible from the information in the previous sections, the student mostly explains on each differential why they thought they were plausible, how the patient met the criteria and why they ruled them out, there may or may not be some errors
23.99 to >0.0 pts
Needs Improvement
Differential diagnoses are minimally plausible from the information in the previous sections, the student minimally explains on each differential why they thought they were plausible, they may or may not discussed how the patient met the criteria and may or may not discussed why they ruled them out, there may or may not be some errors
0 pts
No Marks
30 pts
This criterion is linked to a Learning OutcomeDIAGNOSIS
DSM Final Diagnosis with ICD-10 Code: What is the rationale for the diagnosis? The student should write in detail the rationale that describes the specific symptomatology that qualifies the clinical presentation to be identified as the DSM diagnosis, including diagnostic specifiers.
30 to >26.95 pts
Meets or EAC*
The final diagnosis includes the criteria met along with the ICD 9 code, the rationale is written in detail that described the specific symptomatology that qualifies the clinical presentation as the DSM diagnosis, including diagnostic specifiers, there may or may not be some errors
26.95 to >23.95 pts
Acceptable
The final diagnosis includes the criteria met along with the ICD 9 code, the rationale is mostly written in detail that describes the specific symptomatology that qualifies the clinical presentation as the DSM diagnosis, including diagnostic specifiers, there may or may not be some errors
23.95 to >0.0 pts
Needs Improvement
The final diagnosis includes the criteria met along with the ICD 9 code, the rationale is minimally written in detail and minimally describes the specific symptomatology that qualifies the clinical presentation as the DSM diagnosis, it may or may not include appropriate diagnostic specifiers, there may or may not be some errors
0 pts
No Marks
30 pts
This criterion is linked to a Learning OutcomeTreatment Plan
EBP: In one paragraph or more, review an Evidence-Based Practice article referring to this patient with this particular diagnosis, treatment, or medication (summarize the study, include a rating of the article, (citation for the rating scale & put the article and rating scale in your references), instruments utilized, relevant findings.
10 to >8.9 pts
Meets or EAC*
This section shows critical thinking skills involving evidence-based treatment plan for the patient through a thorough discussion of conclusions drawn based on patient presentation. This section shows continuity between the other sections and all the information in the rubric criteria is present in the paper. There may or may not be some errors.
8.9 to >7.9 pts
Acceptable
This section mostly shows critical thinking skills involving the evidenced-based treatment plan for the patient through a thorough discussion of conclusions drawn based on patient presentation. This section mostly shows continuity between the other sections and mostly all the information in the rubric criteria is present in the paper. There may or may not be some errors.
7.9 to >0.0 pts
Needs Improvement
This section somewhat shows critical thinking skills involving the evidence based treatment plan for the patient through a thorough discussion of conclusions drawn based on patient presentation. This section somewhat shows continuity between the other sections and somewhat of the information in the rubric criteria is present in the paper. There may or may not be some errors.
0 pts
No Marks
10 pts
This criterion is linked to a Learning OutcomeMeasurement of patient progress and Assessment Tools
Measurement of patient progress and Assessment Tools: List 2-3 measures that could be utilized for this patient in the future to measure their progress. Include the name of the test, information about reliability & validity, score ranges, meaning of high vs low scores, how often the instrument should be administered, and patient score is assessed during evaluation. Mnemonic devices, such as “SIGECAPS” are not published/validated tests.
10 to >8.9 pts
Meets or EAC*
This section shows critical thinking skills involving the measurement of patient progress and assessment tools treatment plan for the patient through a thorough discussion of conclusions drawn based on patient presentation. This section shows continuity between the other sections and all the information in the rubric criteria is present in the paper. There may or may not be some errors.
8.9 to >7.9 pts
Acceptable
This section mostly shows critical thinking skills involving the measurement of patient progress and assessment tools treatment plan for the patient through a thorough discussion of conclusions drawn based on patient presentation. This section mostly shows continuity between the other sections and mostly all the information in the rubric criteria is present in the paper. There may or may not be some errors.
7.9 to >0.0 pts
Needs Improvement
This section somewhat shows critical thinking skills involving the evidence based treatment plan for the patient through a thorough discussion of conclusions drawn based on patient presentation. This section somewhat shows continuity between the other sections and somewhat of the information in the rubric criteria is present in the paper. There may or may not be some errors.
0 pts
No Marks
10 pts
This criterion is linked to a Learning OutcomePsychopharmacology
Psychopharmacology: Medication with dose-instructions listed, pharmacodynamics, and pharmacokinetics. A detailed explanation is provided for the choice of this medication over other medications in the same category.
10 to >8.9 pts
Meets or EAC*
This section shows critical thinking skills involving the psychopharmacology treatment plan for the patient through a thorough discussion of conclusions drawn based on patient presentation. This section shows continuity between the other sections and all the information in the rubric criteria is present in the paper. There may or may not be some errors.
8.9 to >7.9 pts
Acceptable
This section mostly shows critical thinking skills involving the psychopharmacology treatment plan for the patient through a thorough discussion of conclusions drawn based on patient presentation. This section mostly shows continuity between the other sections and mostly all the information in the rubric criteria is present in the paper. There may or may not be some errors.
7.9 to >0.0 pts
Needs Improvement
This section somewhat shows critical thinking skills involving the psychopharmacology treatment plan for the patient through a thorough discussion of conclusions drawn based on patient presentation. This section somewhat shows continuity between the other sections and somewhat of the information in the rubric criteria is present in the paper. There may or may not be some errors.
0 pts
No Marks
10 pts
This criterion is linked to a Learning OutcomeDiagnostic tests
Diagnostic tests that are specific to the case are described with the rationale whether or not they are done. Lab/Diagnostic template in Appendix A. List each test separately and provide the rationale (CBC is separated by each test – hemoglobin, hematocrit, etc and what abnormals could mean and the possible connection to a psychiatric diagnosis)
10 to >8.9 pts
Meets or EAC*
This section shows critical thinking skills involving diagnostic test plan for the patient through a thorough discussion of conclusions drawn based on patient presentation. This section shows continuity between the other sections and all the information in the rubric criteria is present in the paper. There may or may not be some errors.
8.9 to >7.9 pts
Acceptable
This section mostly shows critical thinking skills involving the diagnostic test treatment plan for the patient through a thorough discussion of conclusions drawn based on patient presentation. This section mostly shows continuity between the other sections and mostly all the information in the rubric criteria is present in the paper. There may or may not be some errors.
7.9 to >0.0 pts
Needs Improvement
This section somewhat shows critical thinking skills involving the diagnostic test treatment plan for the patient through a thorough discussion of conclusions drawn based on patient presentation. This section somewhat shows continuity between the other sections and somewhat of the information in the rubric criteria is present in the paper. There may or may not be some errors.
0 pts
No Marks
10 pts
This criterion is linked to a Learning OutcomePsychotherapy
Psychotherapy: In one to two paragraphs, list 2 or more theoretical orientations which could be used in the treatment of this patient and give 3-4 sentences describing each theoretical orientation and why the treatment could be beneficial. Such options could include Interpersonal, psychodynamic, EMDR, Rogerian, CBT, Jungian, etc. Use references other than Sadler or Wheeler.
10 to >8.9 pts
Meets or EAC*
This section shows critical thinking skills involving the psychotherapy treatment plan for the patient through a thorough discussion of conclusions drawn based on patient presentation. This section shows continuity between the other sections and all the information in the rubric criteria is present in the paper. There may or may not be some errors.
8.9 to >7.9 pts
Acceptable
This section mostly shows critical thinking skills involving the psychotherapy treatment plan for the patient through a thorough discussion of conclusions drawn based on patient presentation. This section mostly shows continuity between the other sections and mostly all the information in the rubric criteria is present in the paper. There may or may not be some errors.
7.9 to >0.0 pts
Needs Improvement
This section somewhat shows critical thinking psychotherapy treatment plan for the patient through a thorough discussion of conclusions drawn based on patient presentation. This section somewhat shows continuity between the other sections and somewhat of the information in the rubric criteria is present in the paper. There may or may not be some errors.
0 pts
No Marks
10 pts
This criterion is linked to a Learning OutcomePsychoeducation
Psychoeducation: Pertinent information regarding aftercare, legal issues, health promotion such as diet, medical, psychological testing, medications, diagnosis, black box warnings, and educational websites
10 to >8.9 pts
Meets or EAC*
This section shows critical thinking skills involving psychoeducational treatment plan for the patient through a thorough discussion of conclusions drawn based on patient presentation. This section shows continuity between the other sections and all the information in the rubric criteria is present in the paper. There may or may not be some errors.
8.9 to >7.9 pts
Acceptable
This section mostly shows critical thinking skills involving the psychoeducation treatment plan for the patient through a thorough discussion of conclusions drawn based on patient presentation. This section mostly shows continuity between the other sections and mostly all the information in the rubric criteria is present in the paper. There may or may not be some errors.
7.9 to >0.0 pts
Needs Improvement
This section somewhat shows critical thinking skills involving the psychoeducational treatment plan for the patient through a thorough discussion of conclusions drawn based on patient presentation. This section somewhat shows continuity between the other sections and somewhat of the information in the rubric criteria is present in the paper. There may or may not be some errors.
0 pts
No Marks
10 pts
This criterion is linked to a Learning OutcomeFollow-up and written prescription
Follow-up: Instructions to the patient for follow-up visits, emergency access, or diagnostics. Include safety measures if indicated. Use a separate blank piece of paper and write a sample prescription as if you were planning to start this medication on a new patient, including all the components the DEA requires including student signature as PMHNP student.
10 to >8.9 pts
Meets or EAC*
This section shows critical thinking skills involving follow up treatment plan for the patient through a thorough discussion of conclusions drawn based on patient presentation. This section shows continuity between the other sections and all the information in the rubric criteria is present in the paper. There may or may not be some errors. Sample prescription contains all the elements as required by the DEA including student signature as a PMHNP student.
8.9 to >7.9 pts
Acceptable
This section mostly shows critical thinking skills involving the follow up treatment plan for the patient through a thorough discussion of conclusions drawn based on patient presentation. This section mostly shows continuity between the other sections and mostly all the information in the rubric criteria is present in the paper. There may or may not be some errors. Sample prescription contains most of the elements as required by the DEA including student signature as a PMHNP student.
7.9 to >0.0 pts
Needs Improvement
This section somewhat shows critical thinking skills involving the follow up treatment plan for the patient through a thorough discussion of conclusions drawn based on patient presentation. This section somewhat shows continuity between the other sections and somewhat of the information in the rubric criteria is present in the paper. There may or may not be some errors. Sample prescription contains somewhat of the elements as required by the DEA however there is no student signature as a PMHNP student.
0 pts
No Marks
10 pts
This criterion is linked to a Learning OutcomeAPA format
Professionally written, utilizes academic resources published in the last five (5) years, appropriate grammar and sentence structuring, and correct APA referencing and APA format in the template boxes and wherever else that requires APA format.
20 to >17.9 pts
Meets or EAC*
Skillful and proficient use of APA formatting of text, sentence structure, grammar, and reference citation
17.9 to >15.9 pts
Acceptable
Minimal problems with APA formatting of text, sentence structure, grammar, and reference citation
15.9 to >0.0 pts
Needs improvement
Major problems with APA formatting of text, sentence structure, grammar, and reference citation
0 pts
No Marks
20 pts
Total Points: 150
This is a PART TWO with this assignment (the title page is only needed on part one), please review the rubric once in the course. Assessment findings should be relevant, thorough, and reflective of the standards associated with the professional psychiatric mental health nurse practitioner. Your plan should be individualized, based on sound evidence-based practice findings from the literature while incorporating all relevant findings from your assessment.
You should articulate this case study as if you were presenting it to a colleague for consultation or at a professional meeting, you will need to be very detailed in describing the case, and how you came to determine ALL of your findings. “Paint a picture” so to speak so your clinical instructor can imagine everything that you are seeing while seeing the patient. Be very descriptive and support your assessment with evidence. You may choose to develop this Comprehensive Case Study on a challenging or interesting patient encountered during your clinical experiences.
Please be organized and succinct when writing. Remember to proofread for logical flow, grammar, and typographical errors. Try to obtain all of the required information for your case study by reviewing the patient’s chart, talking with the patient and/or support person, and talking with the staff at your clinical site. If you don’t have the information, another patient should be chosen, otherwise, points will be deducted. If the patient was adopted and does not have the information required, choose another patient.
If some part of the required information is not available, you may state that there is no information available AND explain what/how that component of the case study would normally be assessed to include expected normal findings. Include the information that you gathered in the appropriate section without repeating the same information multiple times. When you write any history of events, chronological order is required.
For guidance, review your readings and texts from the corresponding didactic course, other previous texts, and reference books. You must include references to support your assessment, differential diagnosis(es), primary diagnosis, and plan. There must be a minimum of 3 (three) references. At least 1 (one) of the references must be an evidence-based article that is no more than 5 years old in the designated section of the rubric wherein you are also required to must rate and grade the evidence.
When you write your note, do not identify the person by name or initials. Use descriptions such as “the patient, the client, him, he, she, he, they, them, mother, father, husband, wife, first son, second daughter, youngest daughter, paternal grandmother, maternal grandfather, and so on. Do not state the name of the town and state. Use descriptions such as a rural town in a southwestern state, or a large city in a northeastern state, and so on.
PART TWO OF THE COMPREHENSIVE CASE STUDY
Diagnoses
Differentials: Three differential diagnoses including pertinent patient presentation/symptoms that should be considered and must be plausible to match the patient presentation. The student should write in detail WHY they thought the patient met this criterion using the previous information presented in part one and how the diagnosis was ruled out. The final diagnosis should NOT be included in the differential.
DSM-5 Final Diagnosis with ICD-10 Code: What is the rationale for the diagnosis? The student should write in detail the rationale that describes the specific symptomatology that qualifies the clinical presentation to be identified as the DSM-5 diagnosis, including diagnostic specifiers.
Formulating the Treatment Strategy
EBP: Review an Evidence-Based Practice article referring to this patient with this particular diagnosis, treatment, or medication (summarize the study, include a rating of the article, (citation for the rating scale & put the article and rating scale in your references), instruments utilized, relevant findings.
Measurement of patient progress and Assessment Tools: List 2-3 measures that could be utilized for this patient in the future to measure their progress. Include the name of the test, information about reliability & validity, score ranges, meaning of high vs low scores, how often the instrument should be administered, and patient score is assessed during evaluation. Mnemonic devices, such as “SIGECAPS” are not published/validated tests.
Psychopharmacology: Medication with dose-instructions listed, pharmacodynamics, and pharmacokinetics. A detailed explanation is provided for the choice of this medication over other medications in the same category.
Diagnostic tests: Diagnostic tests that are specific to the case are described with the rationale. Lab/Diagnostic template in Appendix A below. List each test separately and provide the rationale (CBC is separated by each test – hemoglobin, hematocrit, etc and what abnormals could mean and the possible connection to a psychiatric diagnosis if applicable.
Psychotherapy: List 2 or more theoretical orientations which could be used in the treatment of this patient and give 3-4 sentences describing each theoretical orientation and why the treatment could be beneficial. Such options could include Interpersonal, psychodynamic, EMDR, Rogerian, CBT, Jungian, etc. Use references other than Sadler or Wheeler.
Psychoeducation: Pertinent information regarding aftercare, legal issues, health promotion such as diet, medical, psychological testing, medications, diagnosis, black box warnings, and educational websites
Follow-up: Instructions to the patient for follow-up visits, emergency access, or diagnostics. Include safety measures if indicated.
References: APA format and writing
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