You need to choose one of the most challenging cases that you have encountered in your practicum. Make sure that you have a mental status exam (MSE) on that patient, along with a patient/family medical, psychiatric, substance use history. Identify the proper CPT code (s) you will be using for this patient.
Be very thorough about your rationale for the preliminary diagnosis of the patient. Identify differential diagnosis. Use the DSM 5 for all diagnoses.
Discuss neurobiological components relating to the disorder (s). Also identify any genetic, psychosocial, medical factors.
Make treatment recommendations, including any appropriate therapies and medications. Give a timeline for the proposed schedule of treatment.
CC/HPI
Mental status addresses all points
Patient and family medical history
Patient and family psychiatric history
Patient and family substance use history
Thorough rationale for diagnosis of patient
Rule/out diagnoses with rationale for considering and plan on how they will be ruled out
Neurobiological basis for problem
Genetic, psychosocial, medical factors and how these will be addressed
Treatment recommendation and rationale
Timeline for any treatment trials/changes, and when you anticipate seeming changes (cited references required)
CPT codes utilized for visit and followup visits
APA format
Rubric
Final comprehensive case study
Final comprehensive case study
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeCC/HPI/Mental status addresses all points
20 pts
This criterion is linked to a Learning OutcomePatient and family medical history
5 pts
This criterion is linked to a Learning OutcomePatient and family psychiatric history
5 pts
This criterion is linked to a Learning OutcomePatient and family substance use history
5 pts
This criterion is linked to a Learning OutcomeThorough rationale for diagnosis of patient
20 pts
This criterion is linked to a Learning OutcomeRule/out diagnoses with rationale for considering and plan on how they will be ruled out
20 pts
This criterion is linked to a Learning OutcomeNeurobiological basis for problem
15 pts
This criterion is linked to a Learning OutcomeGenetic, psychosocial, medical factors and how these will be addressed
15 pts
This criterion is linked to a Learning OutcomeTreatment recommendation and rationale
20 pts
This criterion is linked to a Learning OutcomeTimeline for any treatment trials/changes, and when you anticipate seeming changes (cited references required)
10 pts
This criterion is linked to a Learning OutcomeCPT codes utilized for visit and followup visits
5 pts
This criterion is linked to a Learning OutcomeAPA format
10 pts
Total Points: 150
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