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Initial Evaluation and Diagnosis

Definition:  

A competent psychiatrist skillfully gathers data from appropriate resources and formulates a reasonable diagnosis at the time of an initial encounter.

Portfolio Entry Requirements:  

Select a challenging case from this year, which demonstrates your skill in conducting an initial evaluation and diagnosis. In your cover letter, describe the patient and clinical situation and elaborate upon your thought processes that justify or explain the diagnosis. Provide the initial evaluation and other supporting documents, such as laboratory or radiology reports, past medical records, or literature reviews. A differential diagnosis is necessary to achieve a high rating in this skill.

Initial Evaluation and Diagnosis Scoring Rubric

1

Important skills and/or knowledge lacking to adequately manage the case; lacks skillful approach and/or fails to provide rationale for diagnosis; gross lack of data.

2

Appropriate approach, but weaknesses would likely lead to potential problems; rationale for initial diagnosis is inadequately supported.

3

Competent to successfully evaluate and diagnose standard cases following a conventional approach; provides rationale for diagnosis; complete diagnostic impression.

4

Applies standard approach to evaluation to ensure the initial diagnosis by considering reasonable alternatives among various diagnoses.

5

Well-integrated knowledge and skills facilitate resolution of complex initial evaluation and diagnosis; considers new treatments or interventions; shows knowledge base that supports decision-making.

6

Wide breadth of knowledge and skills and a sophisticated, well integrated approach; utilizes varied sources to manage a very complex evaluation and initial diagnosis.