1. MODULE TITLE: Research Methods and International Project -
part 1 and part 2
Brief introduction to module
This module aims to provide you with the knowledge and skills
that are required to undertake independent research on a topic
that you will be chosen for your final dissertation where you
determine the methodology and approach. In so doing you will
take significant strides on the path to becoming an independent
learner, and feel able to undertake other research tasks, with the
help of your supervisor. The module will provide you with an
understanding of research philosophies; introduce you to a
range of qualitative and quantitative methodologies and
methods of analysis. You will develop your intellectual
reasoning ability as well as your ability to write critically.
During the lecture and seminar classes you will be given
opportunities to discuss and evaluate a range of research
methods and approaches.
Overall assessment (part 1 and 2)
Course work
·
Research Project Proposal (35% of module
marks)
Word count: 2,000 words++
·
International Business Project (65% of
module marks)

2. Students are not to be penalised for exceeding the word count.
They are encouraged to collect and analyse data, as well as
discuss the findings and put forward recommendations, which
requires a lengthier contribution.
Module learning outcomes:
• Be able to demonstrate knowledge and understanding of
research method process, including identifying the research
area, topic and question, critical literature review, research
philosophy
and design, sampling and sampling techniques, data collection
and analysis, synthesis and research dissemination
•
Demonstrate and understand the ethical consideration and issue
as well as value of ethical procedures when conducting research
in business
•
Be able to work collaboratively within a learning community,
time management and self- management as well as the ability to
use research skills in a wider context
•
Be able to develop an appropriate and feasible research proposal
to a specific context
Research Project Proposal (35% of module marks)
The research methods proposal will enable students to build up
a collection of material providing evidence of developing
research skills. The core content of the proposal will consist of
an exercise in each of the following five areas, corresponding to
the Specific Learning Outcomes above (and will include both
individual and group work).
Preliminary literature review should include 10+ references to

3. relevant business/academic studies
Research design and its feasibility should be demonstrated
All potential ethical issues/concerns at each stage of the
research project addressed
The outline of planned empirical investigation (time frame and
resources) spans from the beginning of the project
(brainstorming stage) till the thesis submission deadline.
The mandatory structure of the research proposal is as follows:
Cover page (including the working TITLE, student name,
student
ID, word count)
Table of Contents
1.
Introduction
1.1
Research problem and rationale
1.2
Aim and objectives
1.3
Research questions/hypotheses
2.
Preliminary literature review
3.
Tentative methodological approach
3.1
Research design and purpose
3.2
Target population and sampling procedure
3.3
Indication of data collection sources and instruments
3.4
Indication of data analysis methods/instruments/tests

4. 3.5
Reliability and validity
3.6
Scope and limitations
4.
Ethical concerns
5.
Project time scale and resources
References
(
Appendix)
Note: No data have to be analysed at this stage. Appendix
should be included only if you have preliminary survey
(interview or questionnaire) questions or other part of the
research design to show.
Required number of relevant
academic articles and business reports and other
credible sources to be referenced in the research proposal
(including Introduction):
15+
Marking Grid for Research Proposal
100-80%
79-70%
69-60%
59-50%
49-40%
39-20%
19-0%
20
%
KNOWLEDGE

5. AND
UNDERSTAND
ING
Has a comprehensive/ detailed knowledge of the area to be
investigated and provides a good rationale for a feasible
research project, as well as use of appropriate references to
support the arguments.
Extensive range, depth and complexit y of relevant material.
Clearly defined range and depth of relevant material in all
areas.
Clearly defined range and depth of relevant material in most
areas.
Comprehens ive and relevant detail but lacking depth in some
areas
Has good working knowledg e and relevant detail but lacking
depth in most areas.
Moderate range with some relevant material, little depth.
Poor understan ding of topic, significant irrelevant material
included, did not answer the question.
30
%
APPLICATION
OF
KNOWLEDGE
Demonstration of knowledge
through the use
of relevant examples, explanation of key concepts and terms
Shows
detailed applicatio n of relevant concepts and theories to issues
of study.
All relevant concepts are covered and applied and are relevant
to the area of study.
Most relevant concepts are covered and applied and are relevant
to the area of study.
Understands most concepts which are related to study.

6. Understan ds some concepts which are related to study.
Understa
n ds concepts but applicati o n is
incomple
t e or
inapprop ri ate.
Very limited use of concepts and theories. Applicatio n is not
given or considere d.
Always uses extremely detailed and relevant examples to
support argument.
Significan tl y uses detailed and relevant examples to support
argument.
Mostly uses many
relevant examples to support argument.
Sometimes uses mostly relevant examples, some examples
provided out of context of argument.
Not many relevant examples used to support argument.
Limited and irreleva
nt
example s used.
No use of examples to support argument.
40
%
EVALUATION
of applicable research design, assessment of ethical issues Can
select appropriate research approach, and instruments of data
collection &
Well integrated study with in- depth, original and critical
analysis
In depth and
critical

7. Well integrated study with original and
critical analysis.
Critical evaluatio n of data. All conclusio ns
Largely integrated study with a good level of original and
critical analysis.
Critical evaluation of most data. Most
Mostly integrated study with some
original and critical analysis.
Evaluates using a selection of techniques
Shows an
acceptabl e level of original
and
critical analysis.
Evaluates using a limited selection
Predomin
a tely descriptiv e
, without originalit y or critical analysis.
Unable to make judgeme
nt s about
Wholly
descriptiv e.
Unable to judge the value of informatio n.
analysis, using a wide range of techniques appropriate to the
subject.
Originality/Criti cality
Create new knowledge and going beyond
what is expected
(i.e. extra papers/further readings). Can
critically review evidence supporting research/literatur e gap, as

8. well as
its reliability, validity and significance and can investigate
contradictory information and identify reasons for
contradictions.
evaluation of material. Draws
detailed conclusion s relevant to study.
relevant to study.
conclusions relevant to study.
to judge information. Some
conclusions are not
drawn from the information.
of technique s to judge the value of informati on.
Conclusio ns are not drawn from the informati on.
relevance and significanc e of informatio n.
10
%
COMMUNICA
TION AND
PRESENTATI
ON
Can write effectively and coherently, using academic style,
observes the structure, provides good quality visuals
REFERENCIN
G STYLE
Referencing according to Harvard style, including in-text
citations
and
full list of references
Always communic
ates effectively and excellentl y in an appropriat e format/
language
in a clear and concise manner. No
spelling,
grammatic

9. al or referencin g errors.
Always communicat
es effectively in an appropriate format/lang uage in a clear and
concise manner. Few
spelling,
grammatica
l or referencing errors.
Communica tes effectively in an appropriate format/lang uage.
Usually presents information in a clear and concise manner.
Some
spelling, grammatical or referencing errors.
Mostly communicat
es in an appropriate format/lang uage. Presents information
in a clear and mostly concise manner, sometimes meaning is not
clear.
Some
spelling,
grammatical or referencing errors
Meaning is clear and format
conforms to basic requireme nts.
Limited use of language. Major
spelling, grammati cal and referencin g errors.
Meaning
is clear but use of language
and format
is
inappropri ate.
Significant spelling, grammatic al and referencin g errors.
Does not communic
ate effectively and meaning is unclear. Does not use appropriat
e format/ language. Significan t spelling,
grammatic al and referencin g errors.

10. You are advised to begin thinking about your topic and
supporting literature for your project as early as possible.
You need to choose a problem in an area of business theory (so
that there is published research available) and where there is a
reasonable chance of access to primary data. A reasonable
chance of access is where you already have access to a
proportion of respondents for your research that enables you to
answer your research question.
It is recognised that for some students there may be limited
opportunities to work with business organisations for primary
data collection, so that some projects may emphasise desk
research using secondary sources. Nonetheless you are
encouraged, where possible, to include primary data, which
could include, for example, interviews or a small-scale survey.
If you have access to an organisation, for example through a
part-time job, then you will be encouraged to base your project
on that organisation.
· What business and management topic or topics are you
interested in? Accounting, Economics, Management, Marketing,
Human Resource Management, etc.
· What organisational contacts do you have? Through family,
friends, a part-time job?
65% of module marks
Required structure (note that each chapter should have
numbered sub-sections):
Cover page
Acknowledgements
Abstract/Executive summary
Table of Contents
Chapter 1: Introduction
1.1

11. Background and context
1.2
Research problem and rationale
1.3
Research aim and objectives
1.4
Research questions/hypotheses
1.5
Content of the remaining chapters
Chapter 2: Literature review
2.1 2.2
2.3
(..) (thematic sub-sections, with the last one addressing
literature gap
2.4 (or other sub-section) Literature gap Chapter 3:
Methodology
3.1
Research design and purpose
3.2
Target population and sampling procedure
3.3
Data collection
3.4
Data analysis methods
3.5
Reliability and validity
3.6
Scope and Limitations
3.7
Ethical concerns
Chapter 4: Analysis and discussion of findings
4.1 Analysis of findings (you can choose your own headings in
this chapter)
4.1.1
4.1.2

12. 4.2... (individual subsections)
…
4.? Discussion of findings
(the last section)
Chapter 5: Conclusion and recommendations
5.1 Conclusions
5.2 Recommendations
5.3 Future research outlook
References (15-20+)
(Alphabetically listed, in UoR Harvard formatting style)
Appendix (including, e.g., survey questions, interview
transcripts, additional figures/tables)
Generic Marking Grid for International Project –
indicating the structure
1. Chapter 1: INTRODUCTION WEIGHTING 10/100
MARKING CRITERIA
GENERAL COMMENTS ON THIS SECTION
Is there a clear introduction that discusses the topic of research
and rationale (what & why)? Has the research problem
(including knowledge gap) been stated?
Are the aim and objectives, research questions and/or
hypotheses (including variables) clear, relevant and achievable
(testable)? Have they been further explained in terms of how
and to what extent they were answered/tested?
Do aims, objectives etc. go beyond mere listing, i.e. do they
involve explanation, comparison, criticism or evaluation?
Does the introduction indicate the content of the other chapters?

13. OVERALL IMPRESSION: INTRODUCTION
70 - 100%
60 - 69%
50 - 59%
40 - 49%
20 - 39%
0 - 19%
· Comprehensive background information, definitions and
rationale.
· Clearly and explicitly identifies aim, objectives and
appropriate
research questions / hypotheses.
· Has detailed critique of how they were arrived at and potential
issues.
· Detailed but succinct identification of content of
remaining chapters.
· Good background information,
definitions and rationale.
· Clearly identifies aim, objectives and research questions /
hypotheses.
· Partial critique of aim, objectives and research
questions/hypotheses and potential issues.
· Adequate identification of content of remaining chapters.
· Some good background information but lacking in some
aspects.
· Identifies aim, objectives and research questions /hypotheses
but lacking detail in some aspects.
· Lacking a clear rationale of how they were derived.
· Adequate but not succinct identification of content of
remaining chapters.
· Background information has
some relevance but is lacking in some key aspects.
· Adequate identification of research area(s) but
questions/hypotheses not well articulated or poorly explained

14. · Limited explanation of how they were derived
· Some indication of content of remaining chapters.
· Does give some
indication of research
areas but very limited background information.
· Lacks adequate
identification of aim, objectives and research questions /
hypotheses
· Very limited explanation of how they were derived.
· Limited indication of content of
further chapters
· Irrelevant or very limited background information.
· Does not identify aim
and / or
objectives
and / or research questions / hypotheses.
· No explanation of how they were derived.
· No indication of content of
the remaining chapters.
Chapter 2: LITERATURE REVIEW WEIGHTING 25/100
MARKING CRITERIA
GENERAL COMMENTS ON THIS SECTION
Has a comprehensive range of relevant literature, pertinent to
the aim and RQs of the thesis been selected for review? Is the
impression given that extensive reading on the topic and around
the problem took place and has been relayed?
Are the key themes and issues surrounding the research
questions clearly drawn from the literature?
Does it attempt to compare and contrast a number of relevant
concepts, models or theories in a critical manner or is it merely
descriptive?
Is the theoretical framework used in an effective manner?

15. Are the sources used up to date (current, state-of-the-art
publications), where appropriate, and do they have sufficient
academic weight?
Have sources been acknowledged, cited, and referenced fairly
and properly?
Has the text been well paraphrased and a critical stance is
detectable?
Are the references at the end of the thesis complete and in the
appropriate Harvard referencing style?
Has literature gap been clearly identified and addressed
(including recent citations) at the end?
OVERALL IMPRESSION: LITERATURE REVIEW
70 - 100%
60 - 69%
50 – 59%
40 - 49%
20 - 39%
0 - 19%
· Comprehensive appraisal of relevant literature.
· Critical
appraisal of relevant literature.
· Clear relation to research questions.
· Citations are
correct and appropriate
· Bibliography wide ranging and correct in all aspects.
· Comprehensive appraisal of relevant literature
· High level of critical appraisal.
· Related to research questions.
· Citations mainly correct.
· Bibliography wide ranging but with minor errors.
· Adequate appraisal of mostly relevant literature
· Some critical appraisal.
· Not always relevant to research questions.

16. · Citations correct but some errors.
· Bibliography wide ranging but with some errors.
· Adequate discussion of some relevant literature
· Tends towards the descriptive with very limited critical
appraisal.
· Some relevance to research questions.
· Some citations correct but a number of errors.
· Bibliography limited and
with some errors.
· Literature is limited in
scope or irrelevant.
· Little appraisal and very descriptive.
· Limited relevance to research questions.
· A large number of citation errors.
· Bibliography limited with many errors.
· Poor and limited use of literature.
· Vague understanding of relevance of literature.
· Student
appears to have relied heavily on too few texts.
· No or very few citations used.
· Bibliography very limited and does not adhere to the Harvard
System.
Chapter 3: METHODOLOGY WEIGHTING 20/100
MARKING CRITERIA
GENERAL COMMENTS
THIS SECTION
ON
Is there a clear rationale for methodology, i.e. is the student
aware of nature and types of research, e.g., are distinctions
between qualitative and quantitative, positivist and
interpretative methods addressed?
Have the alternatives been discussed and have the advantages
and disadvantages of chosen methods been evaluated? Has this
understanding informed their choice of approach?

17. Is the research design/methodology described - in relation to all
the research onion layers - justifiable? Are the research
instruments well designed with all questions etc. relevant to
research aims?
Has target population (be it human or non-human) been clearly
described, appropriate sampling techniques names and
explained, sample size (both for primary and secondary data
sets) addressed? Is sampling process described in detail in
relation to the units of analysis, e.g., who the respondents were;
how many were there; why and how were they selected?
Were research instruments approved by supervisor
before implementation?
Is there evidence of care and accuracy in the data collection
process?
Are data analysis methods discussed in detail? Are all
instruments of data collection specifically named, data sets for
secondary data specified, survey design addressed - when
applicable - in sufficient detail?
Are all the applicable methods of data analysis, including
statistical tests, qualitative analysis methods, and the like
clearly names and explained?
Are validity and reliability separately discussed – not only
theoretically, but in relation to potential threats and errors? Has
the reliability test been performed, if applicable?
Has a pilot study been evidenced and evaluated?
Has the scope of the study been clearly delineated, and all the
limitations discussed? Has the methodology been evaluated in
retrospect with suggestions for improvement if the research
were to be undertaken again?
Have the applicable ethical issues/concerns (as related to the
whole research project) been identified and explained in terms
of how they were mitigated?

18. OVERALL IMPRESSION: METHODOLOGY
70 - 100%
60 - 69%
50 - 59%
40 - 49%
20 - 39%
0 - 19%
• Has a very clear and well- articulated academic rationale for
methodology
• Has clear academic rationale for methodology and research
approach but
• Some academic rationale for methodology/ approach but
· Limited methodological rationale.
· Methods have some relevance
· Basic rationale for methodology.
· Methods are mainly
· No attempt at rationale for methodology.
· Describes processes that
and research approach.
· Methods highly relevant to purpose with evidence
of exploring alternative methods and choices well justified.
· Sampling correct in all
aspects and clearly explained.
· Critical evaluation
· Overall approach very well planned and executed.
perhaps not always well articulated?
· Methods largely relevant to purpose with
evidence of exploring alternative
methods but
incomplete justification.
· All elements of sampling theory addressed with some being
well done.
· Evaluation may lack a critical approach in

19. some aspects
· Generally well planned and executed.
lacking detail in areas.
· Methods not
relevant to purpose in all aspects but has some good aspects.
Justification for choice is limited.
· All elements of sampling theory adequately addressed
· Evaluation has been attempted
but is limited in terms of a critical approach.
· There may be shortcomings in the planning and execution.
to purpose but have been insufficiently
planned and executed.
Justification for choice is very limited.
· Sampling theory addressed but limited with omissions.
· Evaluation is attempted and applied but is poor.
· Overall planning and execution weak.
irrelevant to purpose or are poorly explained and difficult to
understand.
· Sampling theory extremely
weak and
lacking detail.
· Limited evaluation
with very little actual application.
· Poorly planned and executed.
do not relate to the purpose.
· No sampling theory discussed.
· No or very limited and vague evaluation.
· Execution
fails to achieve
minimum standard required.
Chapter 4: ANALYSIS & DISCUSSION OF FINDINGS
WEIGHTING 25/100
MARKING CRITERIA
GENERAL SECTION

20. COMMENTS
ON
THIS
Are the findings presented relevant to aims and objectives?
Does any statistical presentation make the most of the data
collected?
Are any qualitative data analysis results categorised and
presented systematically?
Is there any evidence provided of secondary data analysis, if
applicable?
Are the findings presented clearly and interestingly for the
reader to follow, i.e. in tables, charts etc. embedded in the text,
numbered and captioned?
Are the appendices used appropriately for bulky and/or less
interesting/essential data interpretation?
FOR QUESTIONNAIRES Do the appendices contain a data
summary sheet (including the final sample size/number of
responses), a summary questionnaire and details of statistical
analysis undertaken?
FOR INTERVIEWS Do the appendices contain additional
evidence for data collection and exemplary excerpt(s) of
interview transcripts?
FOR OBSERVATIONS Do the appendices contain back up data
on observations carried out?

21. FOR SECONDARY DATA do the appendices contain sources
where data were collected and how they were analysed?
OVERALL IMPRESSION: ANALYSIS & DISCUSSION OF
FINDINGS
70 - 100%
60 - 69%
50 - 59%
40 - 49%
20 - 39%
0 - 19%
· Clear and unambiguous presentation of data.
· Relevant, rigorous and thorough analysis.
· Excellent discussion and evaluation of findings.
· Excellent linkage to the literature.
· Clear presentation of data with few errors.
· Relevant and thorough analysis.
· Good discussion and evaluation of findings.
· Good linkage to the literature but some omissions.
· Generally clear presentation of data but some errors.
· Relevant analysis but lacks thorough approach.
· Discussion and evaluation of findings lacks rigour but
some useful findings.
· Clear but partial linkage to the literature but many omissions.
· Presentation of data is limited or lacks clarity.
· Analysis is basic and
pedantic in many areas.
· Discussion and evaluation is superficial or
relies on unsupported assertions.

22. · Attempts linkage to the literature but not in a clear manner.
· Unclear or confusing presentation of data.
· Analysis is basic and pedantic in all areas.
· Discussion and evaluation very limited or shows lack of
understanding of evidence collected.
· Minimal linkage to the literature.
· Much or all of the data has been presented in an unclear
manner.
· No analysis or trivial.
· No or very limited discussion of findings.
· No or very weak linkage to the literature.
Chapter 5: CONCLUSION AND RECOMMENDATIONS
WEIGHTING 10/100
MARKING CRITERIA
GENERAL COMMENTS
THIS SECTION
ON
Do the conclusions clearly follow on from the findings? Are the
conclusions well-grounded in the evidence and arguments
presented?
Have the aim, objectives and research questions been clearly
reviewed/revisited and addressed?
Are the conclusions discussed in context and are they applicable
to a wider scenario?
Are some sound business/management recommendations put
forward (preferably naming the stakeholders in question) and
are they consistent with the findings and conclusion?
Is the future research direction indicated at the end?

23. OVERALL IMPRESSION: CONCLUSION
70 - 100%
60 - 69%
50 - 59%
40 - 49%
20 - 39%
0 - 19%
• Conclusions
valid and consistent with analysis.
• Conclusions
valid and generally consistent with analysis.
• Conclusions generally valid and partially consistent with
analysis.
• Some valid conclusions but generally inconsistent with
analysis.
• No obvious conclusions drawn or they are inconsistent with
analysis.
· Conclusions do not relate to purpose.
· No attention to aim, objectives
· Comprehensive reference to aim, objectives and research
questions.
· Conclusions discussed in detail and context and recognised
applicable to wider scenario.
· For work based dissertation recommendatio ns are consistent
with findings and conclusions.
· Good reference
to aim, objectives and research questions.
· Conclusions discussed in
context and recognised briefly that
applicable to a wider.
· For work based dissertation
some logical recommendation

24. s.
· Some reference to aim, objectives and research questions.
· Conclusions discussed in context and some recognition of
wider application.
· For work based dissertation some recommendatio ns but may
be questionable
based on findings and conclusions.
· Limited reference to aim, objectives and research questions.
· Conclusions briefly discussed in context and wider context.
· For work based dissertation
limited recommendation
s.
· Very little attention to aim, objectives and
research questions.
· Conclusions very briefly discussed in context.
· For work based dissertation very few appropriate
recommendation
s.
and the research questions.
· Conclusions not discussed in context.
· For work based dissertation no
recommendatio ns
REFERENCES
Alphabetically listed, in Harvard style
APPENDIX
COHERENCE AND PRESENTATION WEIGHTING 10/100
This section considers the overall holistic nature of the
dissertation. Marks should be awarded according to the
descriptors below recognising the overall consistency,
compliance with presentation requirements and coherence of the
dissertation.

25. MARKING CRITERIA
YES
(or few errors)
NO (or many
errors)
Are the overall style and presentation in accordance with
specifications?
Standard title page
Length 5,000++ words
Word count given
Correct pagination
Correct margins
Double spacing for text
Single spacing for indented quotes and references
Numbered chapter and section headings
Tables and figures numbered and captioned correctly
Appropriate font/bolding and italics
Is the abstract a concise (max 1 page) summary of the aim,
methodology and findings/conclusion?
Is the contents page clear, concise and informative?
Are appendices, tables and figures listed and appropriately
referred to?
Has the thesis been spell and grammar checked?
Has the academic style been followed?
Are citations and references in the required (UoR Harvard)
referencing style?

26. Does the thesis have an overall coherence?
Have paraphrasing issues been kept to minimum?
OVERALL IMPRESSION: COHERENCE
70 - 100%
60 - 69%
50 - 59%
40 - 49%
20 - 39%
0 - 19%
· Fulfils all requirements and follows an acceptable style in a
correct manner.
· Easy to read and leads the reader along
a well- argued path.
• Has an overall coherence.
· Fulfils most requirements and follows an acceptable
style in a generally correct manner.
· Presented so that it is easy for reader to follow.
· Is generally coherent although it may lack coherence in
parts.
· Attempts to follow an acceptable
style and
fulfils most of the requirements.
· Not presented with
maximum clarity and sometimes
difficult to follow the argument.
· Some evidence of coherence.
· Generally attempts to conform to requirements and adequately
executed.
· Some aspects of presentation unclear.
· Has limited coherence.
· Does not meet some of the key requirements.

27. · Fails to follow an acceptable
style and some aspects unclear.
· Very little coherence.
· Does not meet many of the key requirements
· Fails to follow an acceptable style and often unclear an untidy.
· No coherence
How will your work be assessed?
Your work will be assessed by a subject expert who will use the
marking grid provided in this assessment brief. When you
access your marked work, it is important that you reflect on the
feedback so that you can use it to improve future assignments.
Referencing
You MUST use the
Harvard referencing style as outlined by University of
Roehampton.
Assignment submissions
The Business School requires a digital version (in Word) of all
assignment submissions. These must be submitted via Turnitin
on the module’s Moodle site by the specified deadline.
Marking and feedback process
Between you handing in your work and then receiving your
feedback and marks, there are a number of quality assurance
processes that we go through to ensure that students receive
marks which reflects their work. A brief summary is provided
below.
·
Step One – The module and marking team meet to agree
standards, expectations and how feedback will be provided.
·
Step Two – A subject expert will mark your work using

28. the criteria provided in the assessment brief.
·
Step Three – A moderation meeting takes place where
all members of the teaching and marking team will review the
marking of others to confirm whether they agree with the mark
and feedback
·
Step Four – Work at Levels 5 and 6 then goes to an
external examiner who will review a sample of work to confirm
that the marking between different staff is consistent and fair
·
Stop Five – Your mark and feedback are processed by
the Office and made available to you.
NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric
Evaluation Exemplar
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND
TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to
include, follow the
Focused SOAP Note Evaluation Template
AND the Rubric
as your guide. It is also helpful to review the rubric in
detail in order not to lose points unnecessarily because you
missed something required. After reviewing full details of the
rubric, you can use it as a guide.
In the
Subjective section, provide:
· Chief complaint

29. · History of present illness (HPI)
· Past psychiatric history
· Medication trials and current medications
· Psychotherapy or previous psychiatric diagnosis
· Pertinent substance use, family psychiatric/substance use,
social, and medical history
· Allergies
· ROS
Read rating descriptions to see the grading standards!
In the
Objective section, provide:
· 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.
Read rating descriptions to see the grading standards!
In the
Assessment section, provide:
· Results of the mental status examination,
presented in paragraph form.
· At least three differentials with supporting evidence. List them
from top priority to least priority. Compare the
DSM-5-TR diagnostic criteria for each differential
diagnosis and explain what
DSM-5-TR criteria rules out the differential diagnosis
to find an accurate diagnosis.
Explain the critical-thinking process that led you to the
primary diagnosis you selected. Include pertinent positives and
pertinent negatives for the specific patient case.
·
Read rating descriptions to see the grading standards!
Reflect on this case. Include: Discuss what you learned and
what you might do differently. Also include in your reflection a

30. discussion related to legal/ethical considerations (
demonstrate critical thinking beyond confidentiality and
consent for treatment!), social determinates of health, health
promotion and disease prevention taking into consideration
patient factors (such as age, ethnic group, etc.), PMH, and other
risk factors (e.g., socioeconomic, cultural background, etc.).
(The FOCUSED SOAP psychiatric evaluation is typically the
follow-up visit patient note. You will practice writing
this type of note in this course. You will be focusing more on
the symptoms from your differential diagnosis from the
comprehensive psychiatric evaluation narrowing to your
diagnostic impression. You will write up what symptoms are
present and what symptoms are not present from illnesses to
demonstrate you have indeed assessed for illnesses which could
be impacting your patient. For example, anxiety symptoms,
depressive symptoms, bipolar symptoms, psychosis symptoms,
substance use, etc.)
EXEMPLAR BEGINS HERE
Subjective:
CC (chief complaint): A
brief statement identifying why the patient is here. This
statement is verbatim of the patient’s own words about why
presenting for assessment. For a patient with dementia or other
cognitive deficits, this statement can be obtained from a family
member.
HPI: Begin this section with patient’s initials, age, race, gender,
purpose of evaluation, current medication and referral reason.
For example:
N.M. is a 34-year-old Asian male presents for medication
management follow up for anxiety. He was initiated sertraline
last appt which he finds was effective for two weeks then
symptoms began to return.

31. Or
P.H., a 16-year-old Hispanic female, presents for follow up to
discuss previous psychiatric evaluation for concentration
difficulty. She is not currently prescribed psychotropic
medications as we deferred until further testing and screening
was conducted.
Then, this section continues with the symptom analysis for your
note. Thorough documentation in this section is essential for
patient care, coding, and billing analysis.
Paint a picture of what is wrong with the patient. First what is
bringing the patient to your follow up evaluation? Document
symptom onset, duration, frequency, severity, and impact. What
has worsened or improved since last appointment? What
stressors are they facing? Your description here will guide your
differential diagnoses into your diagnostic impression. You are
seeking symptoms that may align with many
DSM-5 diagnoses, narrowing to what aligns with
diagnostic criteria for mental health and substance use
disorders.
Substance Use History: This section contains any history or
current use of caffeine, nicotine, illicit substance (including
marijuana), and alcohol. Include the daily amount of use and
last known use. Include type of use such as inhales, snorts, IV,
etc. Include any histories of withdrawal complications from
tremors, Delirium Tremens, or seizures.
Current Medications: Include dosage, frequency, length of time
used, and reason for use. Also include OTC or homeopathic
products.
Allergies:
Include medication, food, and environmental allergies
separately. Provide a description of what the allergy is (e.g.,
angioedema, anaphylaxis). This will help determine a true
reaction vs. intolerance.

32. Reproductive Hx:
Menstrual history (date of LMP), Pregnant (yes or no),
Nursing/lactating (yes or no), contraceptive use (method used),
types of intercourse: oral, anal, vaginal, other, any sexual
concerns
ROS: Cover all body systems that may help you include or rule
out a differential diagnosis. Please note: THIS IS DIFFERENT
from a physical examination!
You should list each system as follows:
General:Head:
EENT: etc. You should list these in bullet format and
document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or
yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing,
congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest
discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or
diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination, urgency, hesitancy,
odor, odd color
NEUROLOGICAL: No headache, dizziness, syncope, paralysis,
ataxia, numbness, or tingling in the extremities. No change in
bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or
stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.

33. LYMPHATICS: No enlarged nodes. No history of splenectomy.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat
intolerance. No polyuria or polydipsia.
Objective:
Diagnostic results: Include any labs, X-rays, or other
diagnostics that are needed to develop the differential diagnoses
(support with evidenced and guidelines).
Assessment:
Mental Status Examination: For the purposes of your courses,
this section must be presented in paragraph form and not use of
a checklist! This section you will describe the patient’s
appearance, attitude, behavior, mood and affect, speech, thought
processes, thought content, perceptions (hallucinations,
pseudohallucinations, illusions, etc.)., cognition, insight,
judgment, and SI/HI. See an example below. You will modify to
include the specifics for your patient on the above elements—
DO NOT just copy the example. You may use a preceptor’s way
of organizing the information if the MSE is in paragraph form.
He is an 8-year-old African American male who looks his stated
age. He is cooperative with examiner. He is neatly groomed and
clean, dressed appropriately. There is no evidence of any
abnormal motor activity. His speech is clear, coherent, normal
in volume and tone. His thought process is goal directed and
logical. There is no evidence of looseness of association or
flight of ideas. His mood is euthymic, and his affect appropriate
to his mood. He was smiling at times in an appropriate manner.
He denies any auditory or visual hallucinations. There is no
evidence of any delusional thinking. He denies any current
suicidal or homicidal ideation. Cognitively, he is alert and
oriented. His recent and remote memory is intact. His
concentration is good. His insight is good.
Diagnostic Impression:
You must begin to narrow your differential diagnosis to
your diagnostic impression. You must explain how and why

34. (your rationale) you ruled out any of your differential
diagnoses. You must explain how and why (your rationale) you
concluded to your diagnostic impression. You will use
supporting evidence from the literature to support your
rationale. Include pertinent positives and pertinent negatives for
the specific patient case.
Also included in this section is the reflection. Reflect on this
case and discuss whether or not you agree with your preceptor’s
assessment and diagnostic impression of the patient and why or
why not. What did you learn from this case? What would you do
differently?
Also include in your reflection a discussion related to
legal/ethical considerations (
demonstrating critical thinking beyond confidentiality
and consent for treatment!), social determinates of health,
health promotion and disease prevention taking into
consideration patient factors (such as age, ethnic group, etc.),
PMH, and other risk factors (e.g., socioeconomic, cultural
background, etc.).
Case Formulation and Treatment Plan
Includes documentation of diagnostic studies that will be
obtained, referrals to other health care providers, therapeutic
interventions including psychotherapy and/or
psychopharmacology, education, disposition of the patient, and
any planned follow-up visits. Each diagnosis or condition
documented in the assessment should be addressed in the plan.
The details of the plan should follow an orderly manner.
*See an example below. You will modify to your
practice so there may be information excluded/included. If you
are completing this for a practicum, what does your preceptor
document?
Risks and benefits of medications are discussed including non-
treatment. Potential side effects of medications discussed (be

35. detailed in what side effects discussed). Informed client not to
stop medication abruptly without discussing with providers.
Instructed to call and report any adverse reactions. Discussed
risk of medication with pregnancy/fetus, encouraged birth
control, discussed if does become pregnant to inform provider
as soon as possible. Discussed how some medications might
decreased birth control pill, would need back up method
(exclude for males).
Discussed risks of mixing medications with OTC drugs, herbal,
alcohol/illegal drugs. Instructed to avoid this practice.
Encouraged abstinence. Discussed how drugs/alcohol affect
mental health, physical health, sleep architecture.
Initiation of (list out any medication and why prescribed, any
therapy services or referrals to specialist):
Client was encouraged to continue with case management and/or
therapy services (if not provided by you)
Client has emergency numbers: Emergency Services 911, the
Client's Crisis Line
1-800-_______. Client instructed to go to nearest ER or
call 911 if they become actively suicidal and/or homicidal.
(only if you or preceptor provided them)
Reviewed hospital records/therapist records for collaborative
information; Reviewed PMP report (only if actually completed)
Time allowed for questions and answers provided. Provided
supportive listening. Client appeared to understand discussion.
Client is amenable with this plan and agrees to follow treatment
regimen as discussed. (this relates to informed consent; you will
need to assess their understanding and agreement)

36. Follow up with PCP as needed and/or for:
Labs ordered and/or reviewed (write out what diagnostic test
ordered, rationale for ordering, and if discussed fasting/non
fasting or other patient education)
Return to clinic:
Continued treatment is medically necessary to address chronic
symptoms, improve functioning, and prevent the need for a
higher level of care.
References (move to begin on next page)
You are required to include at least three evidence-based, peer-
reviewed journal articles or evidenced-based guidelines which
relate to this case to support your diagnostics and differentials
diagnoses. Be sure to use correct APA 7th edition formatting.
© 2022 Walden University
Page 1 of 3
[MUSIC PLAYING] DR. MOORE: Hi. Good afternoon. My
name is Dr. Moore. Am I understanding you're here
for a mental health assessment today? PETUNIA PARK: That's
right. DR. MOORE: OK. So to make sure I have the right
patient and the right chart, can you tell me your name
and your date of birth? PETUNIA PARK: Yes. I'm Petunia Park.
My birthday is July 1, 1995. DR. MOORE: And can you tell
me what today's date is? PETUNIA PARK: So
it's December 1. DR. MOORE: Do you know the year?
PETUNIA PARK: 2020. DR. MOORE: And what day
of the week is this? PETUNIA PARK: It's Tuesday.
[CHUCKLING] DR. MOORE: And do you
know where we are today? PETUNIA PARK: Yes I am here
in the beautiful, sunny office at the clinic. DR. MOORE: OK,
great. Thank you. So can you tell me a little bit

37. about why you're here today? What brings you here today?
PETUNIA PARK: Yes. So I have a history of taking
medications and then stopping them. I don't think I need them. I
really feel like the
medication squashes who I am. DR. MOORE: OK, OK. So I'm
going to be able
to help you with that. But to begin, I'm going
to ask you some questions about your family. I'm going to ask
you some
history-type questions. I'm going to ask
you some symptoms that you might be having. And all of these
questions are going to help me work with you
on a treatment plan, OK? So I would like to
begin with, when was the first time that you
ever had any mental health or substance use
treatment in your life? PETUNIA PARK: OK. Well, when I was
a teenager,
my mom put me in the hospital after I went four or five
days without sleeping. I think I may have been
hearing things at that time. [CHUCKLES] I think they
started me on some medication, but I'm not sure. DR. MOORE:
Oh, OK so
you were hospitalized. How many times have you been
hospitalized for mental health? PETUNIA PARK: Oh, I've been
hospitalized about four times. The last time was
this past spring. No detox or residential
rehabs, though. DR. MOORE: OK, good. Were any of these
hospitalizations due to any suicide gestures? PETUNIA PARK:
One was in 2017. I overdosed on
Benadryl, but I've not had those thoughts since then. DR.
MOORE: Well, I'm very glad
to hear that you've not had any of those thoughts since then.
And I'm glad that you turned
out OK from that overdose. I'm glad that you're here today. Can
you tell me a
little bit about what you've been diagnosed with

38. during your past treatments? PETUNIA PARK: Well,
I think depression, and anxiety, had some
even say maybe bipolar. DR. MOORE: OK, and
what medications have you been tried on
before for those illnesses? And if you can remember,
what was your reactions to those medications? PETUNIA
PARK: Oh, let's see. Oh, I took Zoloft, and that
made me feel really high. [CHUCKLES] I couldn't sleep. My
mind was racing, and
then I took risperidone. That made me gain
a bunch of weight. Seroquel gave me weight, too. I took
Klonopin, and that
seems to slow me down some. I really can't
remember the others. I think the one I just
stopped taking was helping. It started with an L, I think. I don't
really
remember the name, but it squashed
me in creativity. DR. MOORE: OK, well,
we're going to try to help you find some
medication that doesn't make you feel squashed or have any of
those negative side effects today. But in order to do that, I
need some more information. And the next questions I'm going
to ask you are about substances you may have used. And I want
you to know that you
don't get in trouble in here if you've used some
of these substances. It really just helps
me to make sure that what's in your
system that could be impacting your neurochemistry. And when
we do talk
about medications, so I don't give you something
that would negatively interact with something
you may be using, OK? So do you-- PETUNIA PARK: OK. DR.
MOORE: --use any nicotine? PETUNIA PARK: Yes. I smoke
about a pack
a day, and I'm not going to quit for you, either. [CHUCKLES]
Oh. DR. MOORE: That's OK, that's OK. And what about

39. alcohol? When was your last
drink of alcohol? PETUNIA PARK: When I
was 19 because alcohol and me do not work
well together. [CHUCKLES] DR. MOORE: OK, and what
about any marijuana? When was your last
use of any marijuana? PETUNIA PARK: Oh no. I tried that once
and
got really paranoid. DR. MOORE: OK. What about any last
use of cocaine? PETUNIA PARK: Never. DR. MOORE: Last
use of any
stimulants or methamphetamines? PETUNIA PARK: Never. DR.
MOORE: What about
any huffing or inhalants? PETUNIA PARK: Never. DR.
MOORE: OK, have
you used anything like Klonopin or Xanax, any
of those sedative medications? PETUNIA PARK: Never. DR.
MOORE: All right, good. What about any hallucinogenics
like LSD, or PCP, or mushrooms? PETUNIA PARK: No, never.
DR. MOORE: Wonderful. OK, what about any use of pain
pills or opiate medications? Anything prescribed
or anything you've obtained from the street? PETUNIA PARK:
No, never. DR. MOORE: Good. And anything synthetic like
Spice, or ecstasy, Bath Salts, Mollies, anything like that?
PETUNIA PARK: Never. DR. MOORE: Oh, wonderful. Well,
I'm glad to hear that. You know those things
aren't good for your brain. So I encourage you to continue
to stay away from those things. Have you ever had any
blackouts or seizures from drugs or alcohol? Or seen things that
you
weren't sure were there? PETUNIA PARK: Never. DR.
MOORE: Good. What about any legal
issues or any DUIs? PETUNIA PARK: Never. DR. MOORE:
OK. Good, good. All right, so I'm just
going to ask a little bit about your family right now. Any blood
relatives have any
mental health or substance abuse issues? PETUNIA PARK:

40. Yeah, well,
well, why would you ask that? It's not your business. DR.
MOORE: Right. I could see where you
might find that wouldn't be any my business. But really,
sometimes these
issues can be genetic. They're alarm behaviors. So my
understanding
of your family helps me to understand you. PETUNIA PARK:
Huh. Well, my mother
was seen as crazy. I think they said she
had bipolar or something. And my father went
to prison for drugs. And well, we haven't heard,
or seen, or heard from him in 8 or 10 years. My brother, while I
think
he's a little schizo, but he hasn't ever
went to the doctor. Nobody else with anything. DR. MOORE:
OK. So that sounds like
it must be tough growing up not
seeing your father and having some of those
issues in your family. But any family, blood
relatives commit suicide? PETUNIA PARK: Well, my mom
tried, but nobody really did it, you know? DR. MOORE: OK.
Have you ever done anything
like that, or anything like cut on yourself, burn yourself?
PETUNIA PARK: I already told
you, I tried to kill myself. Why ask me that again? No, I'm not
going to kill
myself or anyone else, and I don't cut myself. DR. MOORE:
OK. Well, I'm glad to hear that. And I want you to know
that I am here for you, and we most certainly
will make sure you have a crisis like number
at the end of this session if you do have those
thoughts in the future. So I'm glad to
hear that you don't have those thoughts today. OK. What type of
medical
issues do you have? PETUNIA PARK: Oh, hoo. Let's see. I have

41. a thyroid issue that
I take some medicine for, that hypothyroidism. And I take a
birth control
pill for polycystic ovaries. DR. MOORE: OK, when
was your last menses? PETUNIA PARK: Oh, well I have
a regular one each month. So let's see. It was last month
sometime. DR. MOORE: OK, so any
chance that you're pregnant? PETUNIA PARK:
[LAUGHS] Lordy, no. I may have a lot of sex
around, but I'm safe. DR. MOORE: Hm. You "have a lot of sex
around." Can you maybe tell
me what that means? PETUNIA PARK: Well, it's
exciting and thrilling to find new people to explore sex with. It
helps me keep my
moods high, high, high. [CHUCKLES] DR. MOORE: OK, so
that makes
you feel really high and kind of what, OK? PETUNIA PARK:
Oh yeah. DR. MOORE: So who raised you? PETUNIA PARK:
My mom and
my older brother, mainly. DR. MOORE: And who
do you live with now? PETUNIA PARK: Well, I
live with my boyfriend. And sometimes, stay with my
mom when he gets mad at me for sleeping around some. DR.
MOORE: So that's
created some issues in your relationship, I see. OK. Are you
single, married,
widowed, or divorced? PETUNIA PARK: I've
never been married. DR. MOORE: OK. Do you have any
children? PETUNIA PARK: No. DR. MOORE: All right. Are
you working? PETUNIA PARK: Yes, I work part
time at my aunt's bookstore. She's more tolerant of
the days I don't come in from feeling too depressed. DR.
MOORE: OK, so I hear some,
maybe, feelings of depressed. OK. What is your level of
education? PETUNIA PARK: Oh,
I'm in vo-tech school right now for cosmetology. I'm going to

42. do makeup
for movie stars. [CHUCKLES] DR. MOORE: Oh, that
sounds really wonderful. OK, so but what about now? What do
you do for fun now? PETUNIA PARK: Well, I am
writing my life story, and it's going to be published. I also paint
like Picasso. I'm going to sell those
paintings to movie stars, too. DR. MOORE: Well,
that's wonderful. Maybe someday you can show
me your paintings as well. OK, have you ever been arrested
or convicted for anything? PETUNIA PARK: No. The police did
pick me up and
take me to the hospital once. I didn't have much
sleep that week. And they said I was dancing
around in my nightgown in a field with my guitar. I really don't
remember
much of that, though. I think maybe my mom made
up that story against me because she wanted me to go
back to my boyfriend's house. DR. MOORE: OK, so that was
one of your hospitalizations that we talked about earlier. OK,
what about any history of
trauma with childhood or adult? Any kind of physical,
sexual, emotional abuse? PETUNIA PARK: Well, my
dad was pretty hard on us when he was around. But he didn't
really
touch us or anything. More just yelled at us a lot. DR. MOORE:
OK. All right, so I've
gathered some history here. Now, I want to get
into more of some of the symptoms that brought
you in to see me today. So you mentioned before that
sometimes your depression keeps you from working
at your aunt's bookstore. Can you tell me
a little bit more about what that
looks like for you? PETUNIA PARK: Well, about
four or five times a year, I have these times when I just
don't want to get out of bed. I have no energy, no
motivation to do anything. I just can't feel any

43. interest in my creativity. I feel like I'm not worth
anything because I feel that creativity slipping away. So this is
usually
happening after I've been up for five
days working hard on my works with my writing,
painting, and music. Everyone says I'm
depressed, but I'm not sure. It could be that I'm just
exhausted from working so hard. DR. MOORE: OK, so I hear
you
talking about these creativity episodes right before you crash.
Per se, this depression. Tell me a little bit more
about those episodes. What do those look like for you?
PETUNIA PARK: Oh,
I love those times. Those are the reasons
I don't always take my medication because
I feel like I'm squashed. I have lots of energy
to do a lot of things. I can go four or five days
with very little sleep. I get lots of things
done, but my friends tell me I talk too much
and appear scattered. [SIGHS] They're just jealous
of all the accomplishments I'm getting done. These are the times
I
look to explore my mind and body with feeling good
through sex with other people. DR. MOORE: OK, how long do
those episodes last typically when you have them? PETUNIA
PARK: About a week. DR. MOORE: About a week. OK. So I
want to ask a little bit
more about some other symptoms that maybe we
haven't talked about. Do you feel like you worry
a lot or have any kind of anxiety and panic symptoms?
PETUNIA PARK: No, no no. I'm not a worry. DR. MOORE:
OK, do
you do anything that you feel like you have to
do repetitively over and over? And if you can't do them, you
feel like the end of the world is coming? Something like maybe
count on threes or wash your hands 20 times? Anything like

44. that? PETUNIA PARK: [LAUGHS] No, no. I don't have OCD, if
that's what you're asking. DR. MOORE: OK, what about
hearing or seeing things you're not sure
others see or hear? Anything like that? PETUNIA PARK: Not
right now. It's been a couple of
months since that happened. Sometimes when I'm
not sleeping good, I hear voices telling me how
great and wonderfully talented I am. DR. MOORE: OK. So, but
no voices right now? PETUNIA PARK: No. DR. MOORE: OK,
good. What about your appetite? How's your appetite?
PETUNIA PARK: Well, when
I'm really creative, I'm too busy to eat. And when I'm
crashing and resting, I eat everything in sight. DR. MOORE:
OK, so
what about your sleep? On average, how much time
do you think you sleep in a whole 24-hour period? And do you
have any bad dreams? PETUNIA PARK: No bad dreams. Most
of the time, I get
about five or six hours. When I'm creative,
I'm lucky to get three hours and a whole week. Ugh. And when
I'm crashed, I sleep
about 12 or 16 hours a day. DR. MOORE: OK, wonderful. So
this is great. I have a lot of
information from you that I think we will be able to
come up with a treatment plan and maybe find some
medication that's going to help you feel better
without you feeling so squashed and having negative
side effects, but really help you be able
to function through the day. [MUSIC PLAYING]
NRNP_6665_Week4_Assignment_Rubric
NRNP_6665_Week4_Assignment_Rubric
Criteria
Ratings
Pts
This criterion is linked to a Learning OutcomeCreate

45. documentation in the Focused SOAP Note Template about the
patient in the case study. In the Subjective section, provide: •
Chief complaint• History of present illness (HPI)• Past
psychiatric history• Medication trials and current medications•
Psychotherapy or previous psychiatric diagnosis• Pertinent
substance use, family psychiatric/substance use, social, and
medical history• Allergies• ROS
15 to >13.0 pts
Excellent
The response throughly and accurately describes the patient's
subjective complaint, history of present illness, past psychiatric
history, medication trials and current medications,
psychotherapy or previous psychiatric diagnosis, pertinent
histories, allergies, and review of all systems that would inform
a differential diagnosis.
13 to >11.0 pts
Good
The response accurately describes the patient's subjective
complaint, history of present illness, past psychiatric history,
medication trials and current medications, psychotherapy or
previous psychiatric diagnosis, pertinent histories, allergies,
and review of all systems that would inform a differential
diagnosis.
11 to >10.0 pts
Fair
The response describes the patient's subjective complaint,
history of present illness, past psychiatric history, medication
trials and current medications, psychotherapy or previous
psychiatric diagnosis, pertinent histories, allergies, and review
of all systems that would inform a differential diagnosis but is
somewhat vague or contains minor innacuracies.
10 to >0 pts
Poor
The response provides an incomplete or inaccurate description
of the patient's subjective complaint, history of present illness,
past psychiatric history, medication trials and current

46. medications, psychotherapy or previous psychiatric diagnosis,
pertinent histories, allergies, and review of all systems that
would inform a differential diagnosis. Or the subjective
documentation is missing.
15 pts
This criterion is linked to a Learning OutcomeIn the Objective
section, provide:• Review of Systems (ROS) documentation and
relate if pertinent to the chief complaint, HPI, and history•
Diagnostic results, including any labs, imaging, or other
assessments needed to develop the differential diagnoses
15 to >13.0 pts
Excellent
The response thoroughly and accurately documents the patient's
ROS for pertinent systems. Diagnostic tests and their results are
thoroughly and accurately documented.
13 to >11.0 pts
Good
The response accurately documents the patient's ROS for
pertinent systems. Diagnostic tests and their results are
accurately documented.
11 to >10.0 pts
Fair
Documentation of the patient's ROS is somewhat vague or
contains minor innacuracies. Diagnostic tests and their results
are documented but contain minor inaccuracies.
10 to >0 pts
Poor
The response provides incomplete or inaccurate documentation
of the patient's ROS. Systems may have been unnecessarily
reviewed. Or the objective documentation is missing.
15 pts
This criterion is linked to a Learning OutcomeIn the Assessment
section, provide:• Results of the mental status examination,
presented in paragraph form• At least three differentials with

47. supporting evidence. List them from top priority to least
priority. Compare the DSM-5 diagnostic criteria for each
differential diagnosis and explain what DSM-5 criteria rules out
the differential diagnosis to find an accurate diagnosis. Explain
the critical-thinking process that led you to the primary
diagnosis you selected. Include pertinent positives and pertinent
negatives for the specific patient case.
20 to >17.0 pts
Excellent
The response thoroughly and accurately documents the results
of the mental status exam. Response lists at least three
distinctly different and detailed possible disorders in order of
priority for a differential diagnosis of the patient in the assigned
case study, and it provides a thorough, accurate, and detailed
justification for each of the disorders selected.
17 to >15.0 pts
Good
The response accurately documents the results of the mental
status exam. Response lists at least three distinctly different and
detailed possible disorders in order of priority for a differential
diagnosis of the patient in the assigned case study, and it
provides an accurate justification for each of the disorders
selected.
15 to >13.0 pts
Fair
The response documents the results of the mental status exam
with some vagueness or innacuracy. Response lists at least three
different possible disorders for a differential diagnosis of the
patient and provides a justification for each, but may contain
some vagueness or innacuracy.
13 to >0 pts
Poor
The response provides an incomplete or inaccurate description
of the results of the mental status exam and explanation of the
differential diagnoses. Or the assessment documentation is
missing.

48. 20 pts
This criterion is linked to a Learning OutcomeIn the Plan
section, provide:• Your plan for psychotherapy• Your plan for
treatment and management, including alternative therapies.
Include pharmacologic and nonpharmacologic treatments,
alternative therapies, and follow-up parameters as well as a
rationale for this treatment and management plan. • Incorporate
one health promotion activity and one patient education
strategy.
25 to >22.0 pts
Excellent
The response provides an evidence-based, detailed, and
appropriate plan for psychotherapy for the patient. The response
provides an evidence-based, detailed, and appropriate plan for
treatment and management, including pharmacologic and
nonpharmacologic treatments, alternative therapies, and follow-
up parameters. A strong rationale for the plan is provided that
demonstrates critical thinking and content understanding. ... The
response includes at least one evidence-based health promotion
activity and one evidence-based patient education strategy.
22 to >19.0 pts
Good
The response provides an evidence-based and appropriate plan
for psychotherapy for the patient. The response provides an
evidence-based and appropriate plan for treatment and
management, including pharmacologic and nonpharmacologic
treatments, alternative therapies, and follow-up parameters. An
adequate rationale for the plan is provided. ... The response
includes at least one health promotion activity and one patient
education strategy.
19 to >17.0 pts
Fair
The response provides a somewhat vague or inaccurate plan for
psychotherapy for the patient. The response provides a
somewhat vague or inaccurate plan for treatment and

49. management, including pharmacologic and nonpharmacologic
treatments, alternative therapies, and follow-up parameters. The
rationale for the plan is weak or general. ... The response
includes one health promotion activity and one patient
education strategy, but it may contain some vagueness or
innacuracy.
17 to >0 pts
Poor
The response provides an incomplete or inaccurate plan for
psychotherapy for the patient. The response provides an
incomplete or inaccurate plan for treatment and management,
including pharmacologic and nonpharmacologic treatments,
alternative therapies, and follow-up parameters. The rationale
for the plan is inaccurate or missing. ... The health promotion
and patient education strategies are incomplete or missing.
25 pts
This criterion is linked to a Learning Outcome• Reflect on this
case. Discuss what you learned and what you might do
differently. Also include in your reflection a discussion related
to legal/ethical considerations (demonstrate critical thinking
beyond confidentiality and consent for treatment!), social
determinates of health, health promotion, and disease
prevention that takes into consideration patient factors (such as
age, ethnic group, etc.), PMH, and other risk factors (e.g.,
socioeconomic, cultural background, etc.).
5 to >4.0 pts
Excellent
Reflections are thorough, thoughtful, and demonstrate critical
thinking.
4 to >3.5 pts
Good
Reflections demonstrate critical thinking.
3.5 to >3.0 pts
Fair
Reflections are somewhat general or do not demonstrate critical

50. thinking.
3 to >0 pts
Poor
Reflections are incomplete, inaccurate, or missing.
5 pts
This criterion is linked to a Learning OutcomeProvide at least
three evidence-based, peer-reviewed journal articles or
evidenced-based guidelines that relate to this case to support
your diagnostics and differential diagnoses. Be sure they are
current (no more than 5 years old).
10 to >8.0 pts
Excellent
The response provides at least three current, evidence-based
resources from the literature to support the assessment and
diagnosis of the patient in the assigned case study. The
resources reflect the latest clinical guidelines and provide
strong justification for decision making.
8 to >7.0 pts
Good
The response provides at least three current, evidence-based
resources from the literature that appropriately support the
assessment and diagnosis of the patient in the assigned case
study.
7 to >6.0 pts
Fair
Three evidence-based resources are provided to support the
assessment and diagnosis of the patient in the assigned case
study, but they may only provide vague or weak justification.
6 to >0 pts
Poor
Two or fewer resources are provided to support the assessment
and diagnosis decisions. The resources may not be current or
evidence based.
10 pts

51. This criterion is linked to a Learning OutcomeWritten
Expression and Formatting - The paper follows correct APA
format for parenthetical/in-text citations and reference list.
5 to >4.0 pts
Excellent
Uses correct APA format with no errors
4 to >3.5 pts
Good
Contains a few (one or two) APA format errors
3.5 to >3.0 pts
Fair
Contains several (three or four) APA format errors
3 to >0 pts
Poor
Contains many (five or more) APA format errors
5 pts
This criterion is linked to a Learning OutcomeWritten
Expression and Formatting - English Writing Standards: Correct
grammar, mechanics, and punctuation
5 to >4.0 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors
4 to >3.5 pts
Good
Contains a few (one or two) grammar, spelling, and punctuation
errors
3.5 to >3.0 pts
Fair
Contains several (three or four) grammar, spelling, and
punctuation errors
3 to >0 pts
Poor
Contains many (five or more) grammar, spelling, and
punctuation errors that interfere with the reader’s understanding

52. 5 pts
Total Points: 100
· Review this week’s Learning Resources. Consider the insights
they provide about assessing, diagnosing, and treating mood
disorders.
· Review the Focused SOAP Note template, which you will use
to complete this Assignment. There is also a Focused SOAP
Note Exemplar provided as a guide for Assignment
expectations.
· Review the video,
Case Study: Petunia Park. You will use this case as the
basis of this Assignment. In this video, a Walden faculty
member is assessing a mock patient. The patient will be
represented onscreen as an avatar.
· Consider what history would be necessary to collect from this
patient.
· Consider what interview questions you would need to ask this
patient.
· Consider patient diagnostics missing from the video:
Provider Review outside of interview:
Temp 98.2
Pulse 90
Respiration 18
B/P 138/88
Laboratory Data Available: Urine drug and alcohol screen
negative. CBC within normal ranges, CMP within normal
ranges. Lipid panel within normal ranges. Prolactin Level 8;
TSH 6.3 (H)
Develop a Focused SOAP Note, including your differential

53. diagnosis and critical-thinking process to formulate a primary
diagnosis. Incorporate the following into your responses in the
template:
·
Subjective: What details did the patient provide
regarding their chief complaint and symptomatology to derive
your differential diagnosis? What is the duration and severity of
their symptoms? How are their symptoms impacting their
functioning in life?
·
Objective: What observations did you make during the
psychiatric assessment?
·
Assessment: Discuss the patient’s mental status
examination results. What were your differential diagnoses?
Provide a minimum of three possible diagnoses with supporting
evidence, listed in order from highest to lowest priority.
Compare the
DSM-5-TR diagnostic criteria for each differential
diagnosis and explain what
DSM-5 criteria rules out the differential diagnosis to
find an accurate diagnosis. Explain the critical-thinking process
that led you to the primary diagnosis you selected. Include
pertinent positives and pertinent negatives for the specific
patient case.
·
Plan: What is your plan for psychotherapy? What is
your plan for treatment and management, including alternative
therapies? Include pharmacologic and nonpharmacologic
treatments, alternative therapies, and follow-up parameters as
well as a rationale for this treatment and management plan. Also
incorporate one health promotion activity and one patient
education strategy.

54. ·
Reflection notes: Reflect on this case. Discuss what you
learned and what you might do differently. Also include in your
reflection a discussion related to legal/ethical considerations
(demonstrate critical thinking beyond confidentiality and
consent for treatment!), social determinates of health, health
promotion, and disease prevention that takes into consideration
patient factors (such as age, ethnic group, etc.), PMH, and other
risk factors (e.g., socioeconomic, cultural background, etc.).