P7

• Chief complaint

• History of present illness (HPI)

• Medications

• Psychotherapy or previous
psychiatric diagnosis

• Pertinent histories and/or ROS

accurately and concisely presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis.

accurately presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis.

presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis, but is somewhat vague or contains minor inaccuracies.

presents an incomplete, inaccurate, or unnecessarily detailed/verbose description of the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis. Or subjective documentation is missing.

• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history

• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses

accurately and concisely documents the patient’s physical exam for pertinent systems. Pertinent diagnostic tests and their results are documented, as applicable.

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are documented, as applicable.

Documentation of the patient’s physical exam is somewhat vague or contains minor inaccuracies. Diagnostic tests and their results are documented but contain inaccuracies.

The response provides incomplete, inaccurate, or unnecessarily detailed/verbose documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or objective documentation is missing.

• Results of the mental status examination

• Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.

accurately documents the results of the mental status exam.

presents at least three differentials in order of priority for a differential diagnosis of the patient, and a rationale for their selection. Response justifies the primary diagnosis and how it aligns with DSM-5 criteria.

adequately documents the results of the mental status exam.

presents three differentials for the patient and a rationale for their selection. Response adequately justifies the primary diagnosis and how it aligns with DSM-5 criteria.

presents the results of the mental status exam, with some vagueness or inaccuracy.

presents three differentials for the patient and a rationale for their selection. Response somewhat vaguely justifies the primary diagnosis and how it aligns with DSM-5 criteria.

The response provides an incomplete, inaccurate, or unnecessarily detailed/verbose description of the results of the mental status exam and explanation of the differential diagnoses. Or assessment documentation is missing.

• A treatment plan for the patient that addresses psychotherapy; one health promotion activity and one patient education strategy; plan for treatment and management, including alternative therapies; pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters; and a rationale for the approaches selected.

outlines an evidence-based treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear and concise rationale for the treatment approaches recommended is provided.

The response somewhat vaguely or inaccurately outlines a treatment plan for the patient and provides a rationale for the treatment approaches recommended.

The response does not address the diagnosis or is missing elements of the treatment plan.

Reflections are thorough, thoughtful, and demonstrate critical thinking.

Reflections demonstrate critical thinking.

Reflections are somewhat general or do not demonstrate critical thinking.

Reflections are incomplete, inaccurate, or missing.

The response clearly, accurately, and thoroughly follows the Focused SOAP Note format to document the selected patient case.

The response accurately follows the Focused SOAP Note format to document the selected patient case.

The response follows the Focused SOAP Note format to document the selected patient case, with some vagueness and inaccuracy.

The response incompletely and inaccurately follows the Focused SOAP Note format to document the selected patient case.

Presentation style is exceptionally clear, professional, and focused.

Presentation style is clear, professional, and focused.

Presentation style is mostly clear, professional, and focused

Presentation style is unclear, unprofessional, and/or unfocused.