Unit 15 Assignment – Final Case Formulation
Instructions
- Select a pediatric/adolescent client or case that you have worked with either in your current nursing practice or your PMHNP student clinical setting. Ensure that you correctly remove the appropriate information (name, etc.) to remain HIPAA compliant.
- Prepare a full mental health evaluation on your pediatric/adolescent client. Use the resources presented in the course to help guide your evaluation. Kaplan & Saddock’s Synopsis of Psychiatry has a robust list of the categories of information you should collect and present in your evaluation report (5.1. Parts of the Initial Psychiatric Interview). This should include the following:
-
- A full psychiatric, physical, social, family, and birth and developmental history including verbal reports of the client, your observations of the client, and a summary of any diagnostic aids that you have used.
-
- The use of at least one psychiatric screening or assessment tool from the literature to assist in your assessment of the client
-
- A full physical assessment in addition to the mental status exam and psychiatric history
- Develop a DSM-5 diagnostic assessment:
-
- Support your diagnosis through a thoughtful, evidence-based rationale of the data collected in your evaluation.
- Propose a practical, evidence-based plan of care:
-
- Keep in mind the role of the psychiatric-mental health nurse practitioner is to assess all aspects of the patient’s health status, including health promotion, and disease prevention. Psychiatric care is interdisciplinary. Your plan of care may include the use of other mental health professionals for the delivery of appropriate care. For example, someone who has chronic back pain, and has been out of work may have these factors contributing to his or her depression and may require a pain specialist and social services to address that aspect of the client’s poor psychological functioning.
Requirements
- Support your assessment, diagnosis, treatment, and management plan with appropriate literature citations.
- The SOAP note should be no more than ten pages in length, not including the title and reference pages.
- Use current APA formatting and citations.
- Acronyms should not be used.
- The assessment must be well written and be of professional quality. It must be clear, and well developed, free of spelling, grammatical, and syntactical errors, and in full sentences format.
Rubric
NU674 Unit 15 Assignment – Final Case Formulation Rubric
NU674 Unit 15 Assignment – Final Case Formulation Rubric
CriteriaRatingsPts
This criterion is linked to a Learning OutcomeSubjective Data
10 pts
Level 5
Includes all relevant subjective data necessary for differentiation of the client’s problem. Data is presented in a systematic, organized manner consistently.
7 pts
Level 3
Includes most subjective data with omission of two minor details or one major detail. Most data is presented in a systematic, organized manner.
4 pts
Level 1
Includes subjective data but omits four minor details or two major details. Some data is presented in a systematic, organized manner.
0 pts
Level 0
Does not meet the Section
10 pts
This criterion is linked to a Learning OutcomeObjective Data
10 pts
Level 5
Objective data is complete and consistently presented in an organized manner.
7 pts
Level 3
Objective data is complete and presented in an organized manner most of the time.
4 pts
Level 1
Objective data is not complete or is not presented in an organized manner.
0 pts
Level 0
Does not meet the Section
10 pts
This criterion is linked to a Learning OutcomeAssessment
10 pts
Level 5
Assessment, including differential and/or diagnosis (if appropriate), is complete and appropriate to client. Diagnostics are complete and appropriate to clients.
7 pts
Level 3
Assessment, including differential and/or diagnosis (if appropriate), is complete but some may not be appropriate for clients.
4 pts
Level 1
Assessment, including differential and/or diagnosis (if appropriate), is not complete but is appropriate.
0 pts
Level 0
Does not meet the Section
10 pts
This criterion is linked to a Learning OutcomePlan
10 pts
Level 5
Plan includes all relevant measures 95% to 100%. Pharmacologic Non-pharmacologic Education Referral Follow-up
7 pts
Level 3
Plan includes all relevant measures 89% to 94% Pharmacologic Non-Pharmacologic Education Referral Follow-up.
4 pts
Level 1
Plan includes four of the five relevant measures, but the four are complete.
0 pts
Level 0
Does not meet the Section
10 pts
This criterion is linked to a Learning OutcomeProfessional Application
10 pts
Level 5
Case incorporates four evidence-based practice articles.
7 pts
Level 3
Case incorporates three evidence-based practice articles.
4 pts
Level 1
Does not include an evidence-based practice article but has two or more advanced practice articles.
0 pts
Level 0
Does not meet the Section
10 pts
This criterion is linked to a Learning OutcomeCollege-level academic writing
10 pts
Level 5
Includes no more than three grammatical, spelling, or punctuation errors that do not interfere with the readability. Meets the assignment length requirements.
7 pts
Level 3
Includes no more than four grammatical, spelling, or punctuation errors that do not interfere with the readability. Meets the length requirements.
4 pts
Level 1
Includes five or more grammatical, spelling, and punctuation errors make understanding parts of assignment difficult but does not interfere with readability. Meets the length requirements.
0 pts
Level 0
Does not meet the Section
10 pts
Total Points: 60
Write From Scratch