Assess signs and symptoms of each DSM-5 diagnosis related to substances, trauma, anxiety, depression, and bipolar disorders
Assess signs and symptoms of each DSM-5 diagnosis related to substances, trauma, anxiety, depression, and bipolar disorders. Develop Signs and Symptoms, Rationale, & Current Medications: Assessment using DSM-5 symptoms – details on the Grading Rubric below.
CLINICAL VIGNETTE PART 2 RUBRIC
Criterion
Not Completed
Missing Information
Completed
Brief History of the Presenting Problem: Summarize the person’s biopsychosocial information in detail – use headings:
[a] Background (could take 2 – 3 pages of background) of the person’s childhood to current age regarding family system, school, potential trauma, grief and loss, etc. history.
[b] Supports: What are the client’s strengths? What has been done about the problem [in brief]? What are the client’s personal, social, community resources? How does the client utilize the resources?
[c] Your view: What is your view of the problem? What are your expectations of the client?
Current Diagnosis and Medications
[a] Make a list of the person’s current diagnoses.
[b] List the associated medications.
ADD to Vignette 2:
[c] State whether you CONTINUE TO agree or disagree with the diagnoses and WHY.
Signs and Symptoms, Rationale, Current Medications: Assessment using DSM-5 symptoms
[a] Define the person’s “challenging behaviors” and other behavioral
manifestations of possible symptoms and/or actions of the person.
[b] State what behaviors may relate to signs/symptoms of diagnoses covered from session 1 through 4 (substance-related; PTSD; anxiety; depression; bipolar).
[c] Assess the person and determine possible Differential Diagnoses (Substance-related, trauma, anxiety, and depression).
[d] Make a list of ruled out diagnoses.
[e] Give a rationale for each differential diagnosis.
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