Therapeutic intervention

47 years old female with history of bipolar present for follow up. During her last appointment she discussed having a baby, due to lithium medication she on the care provider told her that the medication can cause heart defect on the fetus. She denies depression at the moment and said sleep is better. She stated she always feels tired in the morning and take iced coffee to keep her going. Her relationship is fine and stated deferring getting pregnant for now due to the side of lithium.

Therapeutic intervention

Medication management: Lamotrigine 100mg, lithium 300mg morning and 600mg evening, paliperidone 6mg, clozapine .5mg as needed, and seroquel 400mg every night.

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Description of chief complaint and history of present illness 5 (5%) – 5 (5%)

The student provides an accurate, clear, and complete description of the chief complaint and history of present illness.

4 (4%) – 4 (4%)

The student provides an accurate description of the chief complaint and history of present illness.

0 (0%) – 0 (0%) 0 (0%) – 3 (3%)

The student provides a vague, inaccurate, or incomplete description of the chief complaint and history of present illness, or description is missing.

Description of past psychiatric, substance use, medical, social, and family history 5 (5%) – 5 (5%)

The student provides an accurate, clear, and complete description of past psychiatric, substance use, medical, social, and family history.

4 (4%) – 4 (4%)

The student provides an accurate description of past psychiatric, substance use, medical, social, and family history.

0 (0%) – 0 (0%) 0 (0%) – 3 (3%)

The student provides a vague, inaccurate, or incomplete description of psychiatric, substance use, medical, social, and family history, or description is missing.

Discussion of most recent mental status exam and observations made during interview and review of systems 14 (14%) – 15 (15%)

The student provides an accurate, clear, and complete discussion of results from most recent mental status exam and observations made during interview and review of systems.

12 (12%) – 13 (13%)

The student provides an accurate discussion of results from most recent mental status exam and observations made during interview and review of systems.

11 (11%) – 11 (11%)

The student provides a vague, inaccurate, or incomplete discussion of results from most recent mental status exam and observations made during interview and review of systems.

0 (0%) – 10 (10%)

All or most of the discussion is inaccurate or missing.

Discussion of diagnostics with results 9 (9%) – 10 (10%)

The student provides an accurate, clear, and complete discussion of diagnostics with results.

8 (8%) – 8 (8%)

The student provides an accurate discussion of diagnostics with results.

7 (7%) – 7 (7%)

The student provides a vague, inaccurate, or incomplete discussion of diagnostics with results.

0 (0%) – 6 (6%)

All or most of the discussion is inaccurate or missing.

Diagnosis with three (3) differentials 23 (23%) – 25 (25%)

The student provides an accurate, clear, and complete diagnosis with three (3) differentials.

20 (20%) – 22 (22%)

The student provides an accurate diagnosis with three (3) differentials.

18 (18%) – 19 (19%)

The student provides a vague, inaccurate, less than 3 or incomplete diagnosis with differentials.

0 (0%) – 17 (17%)

All or most of the discussion is inaccurate or missing. Less than 2 diagnosis.

Comprehensive Psychiatric Evaluation documentation 23 (23%) – 25 (25%)

The response clearly, accurately, and thoroughly follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.

20 (20%) – 22 (22%)

The response accurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.

18 (18%) – 19 (19%)

The response follows the Comprehensive Psychiatric Evaluation format to document the selected patient case, with some vagueness and inaccuracy.

0 (0%) – 17 (17%)

The response incompletely and inaccurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case.

 

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