Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders Essay

 Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders Essay


CC (chief complaint): ‘I am scared. I don’t want to be what people say I am because I ant going to change. I can’t.’

HPI: Lisa is a 29-year-old female that is in West Palm Beach, FL detox facility thinking about long-term rehab. Lisa has a history of smoking crack cocaine, cannabis, and taking alcohol. She reports smoking crack cocaine for approximately $100 daily, cannabis 1-2 times weekly, and alcohol 2-3 drinks weekly. Lisa reports that she fears being admitted to rehab due to fear of stigmatization and difficulties in being employed thereafter. Lisa has a history of theft convictions and drug possession. She is on 2-year probation with randomized drug screens. She has been trying to find a pattern for the calls for her not to test dirty urine. Lisa reports that the use of crack cocaine relieves her distressing experience due to cocaine addiction.

Past Psychiatric History:

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  • General Statement: ‘I am scared. I don’t want to be what people say I am because I ain’t going to change. I can’t.’
  • Caregivers (if applicable): none
  • Hospitalizations: no history of hospitalizations provided.
  • Medication trials: no history of medication trials.
  • Psychotherapy or Previous Psychiatric Diagnosis: No history of previous psychotherapy. Lisa has a history of substance abuse disorder, as she has past drug possessions and theft convictions. She is also currently on 2-year probation with randomized drug screens.

Substance Current Use and History: Lisa has a history of smoking crack cocaine approximately $100 daily, cannabis 1-2 times weekly, and 2-3 alcohol drinks once weekly.

Family Psychiatric/Substance Use History: There is positive substance abuse and psychiatric conditions in the family. Lisa’s mother has a history of anxiety and the use of benzodiazepine. Lisa’s brother has a history of opioid use. Her father has a history of drug abuse and is currently in prison for sexually abusing her.

Psychosocial History: Lisa currently lives with her boyfriend, Jeremy. She has a daughter who lives with her friends. She is employed in a hospital where she has been using drugs to avoid being identified to be suffering from substance abuse disorder. She lives with her boyfriend in a rented house. Lisa fears the stigmatization that she would experience should she be admitted to the rehab.

Medical History:


  • Current Medications: Lisa is currently not on any medications
  • Allergies: Lisa is allergic to amoxicillin. She does not have any allergy to food or environmental agents such as pollen.
  • Reproductive Hx: Lisa has one daughter who currently lives with her friends. She is sexually active, as she lives with her boyfriend, Jeremy. Any other significant reproductive history is not given.



  • GENERAL: The patient appears well-groomed for the occasion. She appears slightly underweight compared to individuals of her age. She demonstrates mild tremors of the upper extremities. She denies fever or child.
  • HEAD/NECK: The client denied lymphadenopathy, neck pain, rigidity, distended veins, and pain in swallowing. The head is normocephalic with no evidence of trauma or unequal hair distribution
  • EYES: The client denied vision changes, drainage, pain, or double vision. She does not use corrective lenses.
  • EARS/NOSE/MOUTH/THROAT: The patient denied changes in hearing, ear drainage, ear pain, and infections. She also denied nasal congestion, drainage, and nose bleeds. She denied halitosis, difficulties in swallowing, bleeding gums, sore throat, and sore tongue.
  • CARDIOVASCULAR: The client denied chest pain and palpitations.
  • PULMONARY:  The client denied shortness of breath, cough, dyspnea, wheezing, and chest pain.
  • GASTROINTESTINAL: The client denied abdominal tenderness, constipation, diarrhea, and bloating.
  • GENITOURINARY: The client denied urinary incontinence, painful urination, and increased frequency of urination.
  • MUSCULOSKELETAL:  The patient denied muscle pain, fractures, tenderness, and muscle weakness.
  • INTEGUMENTARY:  The client denied rashes, lumps, bruises, and lacerations.
  • NEUROLOGICAL:  The client reported the presence of upper arm tremors. She denied headache, dizziness, vomiting, and nausea.
  • PSYCHIATRIC: The client has a history of substance abuse disorder.
  • ENDOCRINE: The client denied cold or heat intolerance, polydipsia, and polyphagia.
  • HEMATOLOGIC/LYMPHATIC:  The patient denied lymphadenopathy.
  • ALLERGIC/IMMUNOLOGIC:  The client denied any history of food or environmental allergies. She is allergic to amoxicillin.

Objective: T-99.8, P-101, R-20, BP 178/94, Ht-5’6, Wt-140lbs

Physical exam: if applicable

Diagnostic results: Lisa’s admission lab works were done. The results were abnormal for ALT 168, AST 200, ALK 250, bilirubin 2.5, albumin 3.0, and GGT 59. UDS was positive for cocaine, and THC. It was negative for alcohol or other drugs. Other labs were within the normal range with BAL being 3.0.


Mental Status Examination: Lisa is a 29-year old female who appears dressed for the occasion. She oriented to self, time, space, and events. She demonstrates mild tremors of the upper limbs. She appears anxious and fearful about being in rehab. Lisa denies illusions, delusions, and hallucinations. Her thought process is intact. She demonstrates the repetition of words during the assessment. She does not have suicidal thoughts, plans, or attempts.

Differential Diagnoses:

  1. Substance use disorder: Lisa’s primary diagnosis is substance use disorder. According to DSMV, substance use disorders arise from the use of drugs that include cannabis, caffeine, hallucinogens, inhalants, sedatives, opioids, anxiolytics, stimulants, and tobacco among others. A patient is diagnosed with the disorder if he presents with specific complaints. They include taking the drug in larger quantities or for a prolonged duration, wanting to stop or cut down the drug or substance but unsuccessful, and spending too much time in getting, using, or recovering from the substance (Proctor et al., 2019). It also includes suffering from urges or cravings for the drug, failing to perform in social and occupational roles due to substance use, and continuing substance use despite affecting relationships and performance. Patients must also give up their social and occupational activities for the substance, using the substance despite putting them in danger, and needing more of the drug to achieve the desired effect. Patients also develop withdrawal symptoms if they stop taking the drug, which can be relieved by taking the drug (John et al., 2018). Lisa meets most of the above criteria for being diagnosed with substance use disorder. She uses caffeine, cannabis, and alcohol. She also depends on caffeine to function optimally. Lisa is aware of the negative effects of substance abuse and has not its use despite being informed about its effects. Substance abuse has also affected her occupational functioning, roles, and success of their business and relationships. Therefore, substance use disorder is Lisa’s primary diagnosis.
  2. Generalized anxiety disorder: Generalized anxiety disorder is the secondary diagnosis that should be considered for Lisa. According to DSMV, patients are diagnosed with an anxiety disorder if they experience excessive anxiety and worry that cause behavioral disturbances. The excessive fear and worry should occur for at least six months with patients finding it hard to control their emotions. The accompanying symptoms include being restless, easily fatigued, irritable, and experiencing sleep disturbances and muscle tension (Munir et al., 2022). Lisa reports fear of rehab and the stigma associated with rehabilitation. As a result, the fear that she experiences does not qualify her to be diagnosed with a generalized anxiety disorder since it has not occurred for a long period and is not associated with any of the above accompanying symptoms.
  3. Post-traumatic stress disorder: The other secondary differential that should be considered for Lisa is post-traumatic stress disorder. Post-traumatic stress disorder is mainly diagnosed in individuals with traumatic experiences (Price et al., 2019). The DSMV sets criteria that should be met for a patient to be diagnosed with post-traumatic stress disorder. They include direct or indirect exposure to traumatic events and symptoms that include intrusion, negative changes in mood and thoughts, avoidance, and changes in reactivity and arousal. The symptoms should persist for at least one month and cause significant interference with life or distress. The symptoms should not be attributable to other causes such as medical conditions, medication use, and substance abuse (Carmassi et al., 2020). Lisa has a traumatic experience of being sexually abused by her father. However, the traumatic experience does not cause symptoms that include avoidance, intrusion, changes in mood and thought processes, reactivity, and arousal, hence, it is the least likely diagnosis for her.


Reflections: Lisa’s case study has increased my understanding of substance abuse disorders. It expanded my understanding of the different symptoms and criteria that should be considered in diagnosing patients with the disorder. I believe that I developed an accurate diagnosis for the patient. One of the things that I would do differently should I encounter a similar patient is to explore the social factors that influence substance abuse. Social factors such as unstable families and peer pressure may affect clients’ efforts to abstain from substances (Sliedrecht et al., 2019). As a result, exploring them would inform the adoption of effective treatment interventions. Ethical considerations that include the promotion of safety in the adopted treatments guide the management of substance use disorders. Providers should also incorporate patients’ views into the treatment plans as a way of ensuring autonomy in the treatment process. Lisa should be educated about lifestyle and behavioral interventions that she needs to adopt to facilitate weight and blood pressure control.


Carmassi, C., Bertelloni, C. A., Cordone, A., Cappelli, A., Massimetti, E., Dell’Oste, V., & Dell’Osso, L. (2020). Exploring mood symptoms overlap in PTSD diagnosis: ICD-11 and DSM-5 criteria compared in a sample of subjects with Bipolar Disorder. Journal of Affective Disorders, 276, 205–211.

John, W. S., Zhu, H., Mannelli, P., Schwartz, R. P., Subramaniam, G. A., & Wu, L.-T. (2018). Prevalence, patterns, and correlates of multiple substance use disorders among adult primary care patients. Drug and Alcohol Dependence, 187, 79–87.

Munir, S., Takov, V., & Coletti, V. A. (2022). Generalized Anxiety Disorder (Nursing). In StatPearls. StatPearls Publishing.

Price, M., Legrand, A. C., Brier, Z. M. F., & Hébert-Dufresne, L. (2019). The symptoms at the center: Examining the comorbidity of posttraumatic stress disorder, generalized anxiety disorder, and depression with network analysis. Journal of Psychiatric Research, 109, 52–58.

Proctor, S. L., Hoffmann, N. G., & Raggio, A. (2019). Prevalence of Substance Use Disorders and Psychiatric Conditions Among County Jail Inmates: Changes and Stability Over Time. Criminal Justice and Behavior, 46(1), 24–41.

Sliedrecht, W., de Waart, R., Witkiewitz, K., & Roozen, H. G. (2019). Alcohol use disorder relapse factors: A systematic review. Psychiatry Research, 278, 97–115.



An important consideration when working with patients is their cultural background. Understanding an individual’s culture and personal experiences provides insight into who the person is and where he or she may progress in the future. Culture helps to establish a sense of identity, as well as to set values, behaviors, and purpose for individuals within a society. Culture may also contribute to a divide between specific interpretations of cultural behavior and societal norms. What one culture may deem as appropriate another culture may find inappropriate. As a result, it is important for advanced practice nurses to remain aware of cultural considerations and interpretations of behavior for diagnosis, especially with reference to substance-related disorders. At the same time, PMHNPs must balance their professional and legal responsibilities for assessment and diagnosis with such cultural considerations and interpretations.
For this Assignment, you will practice assessing and diagnosing a patient in a case study who is experiencing a substance-related or addictive disorder. With this and all cases, remember to consider the patient’s cultural background.
To Prepare:
Review this week’s Learning Resources and consider the insights they provide.
Review the Comprehensive Psychiatric Evaluation template, which you will use to complete this Assignment.
Select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
Consider what history would be necessary to collect from this patient.
Consider what interview questions you would need to ask this patient.
Identify at least three possible differential diagnoses for the patient.
Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.
Incorporate the following into your responses in the template:
Subjective: What details did the patient provide regarding their chief complaint and symptomology 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 priority to lowest 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.
Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), 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.).

00:00:00 [sil.]
00:00:20 LISA Well I had to be here in this hospital if that answers your question.
00:00:25 OFF CAMERA Yes, thank you. Can I get you a drink of water or something else to drink? Anything?
00:00:35 LISA A drink isn’t going to convince me, right? You’re going to have to convince me.
00:00:40 OFF CAMERA What is you want me to persuade you to do?
00:00:45 LISA Going to rehab.
00:00:50 OFF CAMERA What worries you about going to rehab?
00:00:55 [sil.]
00:01:00 LISA Everything.
00:01:00 OFF CAMERA Okay. I tell you what let’s go back a little bit and tell me about how you’re feeling today.
00:01:10 LISA Scared.
00:01:15 OFF CAMERA Can you tell me more about that feeling of being scared?
00:01:20 LISA Well, I don’t want to be. I don’t want to be what people say I am because if I say it and I’m not going to say it because I ain’t going to change. I can’t.
00:01:35 OFF CAMERA What do people say you are?
00:01:40 LISA And I’m not.
00:01:45 OFF CAMERA What don’t you want to be?
00:01:45 LISA An addict.
00:01:50 OFF CAMERA Do you use drugs and alcohol?
00:01:50 LISA Yeah sometimes I have a drink. You know with friends [inaudible] but it doesn’t matter. I’m in control.
00:02:00 OFF CAMERA Do you feel in control now?
00:02:05 LISA Maybe I could just get that drink [inaudible].
00:02:10 OFF CAMERA Sure. Sure. Here you go.
00:02:15 LISA Thank you.
00:02:20 [sil.]
00:02:30 LISA You know what I just think I should leave.
00:02:30 OFF CAMERA You keep saying you should leave. You said that earlier but do you really want to leave?
00:02:40 LISA No.
00:02:45 OFF CAMERA Okay. Tell me why you are here.
00:02:45 LISA Because I’m scared.
00:02:50 OFF CAMERA You said that earlier. You think if you could — then I could figure out together why you’re scared and maybe we can come up to a plan. Up with a plan and if we do that, then maybe your fears will disappear.
00:03:05 LISA No not these fears [inaudible] because it’s over.
00:03:10 OFF CAMERA What’s over?
00:03:10 LISA Everything. The business.
00:03:15 OFF CAMERA What do you mean?
00:03:20 LISA Jeremy.
00:03:25 OFF CAMERA Who is Jeremy?
00:03:25 LISA He’s my boyfriend. I saw him naked with Alisa [assumed spelling] with the same fucking name as me. We now have the same fucking boyfriend. In my office, he was screwing that fucking cunk.
00:03:45 OFF CAMERA So you’re the one who caught Jeremy cheating?
00:03:55 LISA Yeah. Cheating? Yeah that’s a clever word shrinks use.
00:04:05 OFF CAMERA So you and Jeremy share an office?
00:04:05 LISA Yeah we do commercials for local businesses, you know, build websites, that kind of stuff. We started a business together. He moved in with me.
00:04:15 OFF CAMERA How long ago was that?
00:04:20 LISA Nine months.
00:04:20 OFF CAMERA Do you have any children?
00:04:20 LISA Not with that fucking asshole.
00:04:25 [sil.]
00:04:30 LISA I have a daughter, Sarah. Gosh, she’s beautiful. She stays with some friends. She’s not related to Jeremy, thank God.
00:04:45 OFF CAMERA And where are you staying?
00:04:45 LISA I’m renting a place far away from here. You know I ran down to the bank to empty both our bank accounts.
00:04:55 OFF CAMERA Business accounts?
00:04:55 LISA Yeah. And do you know that asshole has been draining them for 4 months? I swear.
00:05:05 OFF CAMERA Taking money out of your account without your knowledge.
00:05:05 LISA Yeah. For his buys.
00:05:10 OFF CAMERA Buys?
00:05:10 LISA Yeah, to payoff his debts with my money.
00:05:20 OFF CAMERA Or crack cocaine?
00:05:25 LISA Yeah for crack.
00:05:25 OFF CAMERA How long have you know he’s been smoking crack?
00:05:30 LISA Ever since I saw him with that — every since I saw with her naked. The both of them naked.
00:05:40 OFF CAMERA What was that like seeing Jeremy and Alisa naked and smoking crack?
00:05:40 LISA Well have you ever seen someone you love naked smoking crack?
00:05:45 OFF CAMERA No.
00:05:50 LISA Yeah no I didn’t think so.
00:05:50 OFF CAMERA So what has that been like for you knowing Jeremy’s smoking crack?
00:05:55 LISA Well, I’ve never seen him do drugs before. You know he drinks a lot, smokes weed, but crack cocaine. I mean God have mercy.


00:06:15 OFF CAMERA What are you thinking about?
00:06:20 LISA Everyone’s going to know.
00:06:25 OFF CAMERA Know what?
00:06:30 LISA That I was getting high to stay in this hospital and get cleaned up.
00:06:35 OFF CAMERA You mean rather than go to rehab.
00:06:40 LISA Rehab, man they’re fucking dirty places and I’m sick and tired of dirty places.
00:06:45 OFF CAMERA No, no, no this rehab place is very clean. I’ve seen it. There are a lot of nice people there. People who feel like they get much better help than here in the hospital. In fact, I can call someone for you and let you talk with them.
00:06:55 LISA No, no, no, no, no, no, no, no, don’t do that.
00:07:00 OFF CAMERA You’re really fearful of going to rehab.
00:07:05 LISA Well if everyone finds out that I’ve been to rehab, I won’t get a job. I won’t be hired anyway.
00:07:10 OFF CAMERA Plus if people are fearful of the stigma and fearful of what people will think of them.
00:07:20 LISA Yeah, but he says that I’m not addicted. It’s just — you know something wrong with my personality.
00:07:25 OFF CAMERA Who says there’s something wrong with your personality?
00:07:30 LISA Jeremy.
00:07:30 OFF CAMERA When did he tell you that?
00:07:35 LISA Lots of times.
00:07:35 OFF CAMERA I thought you said you and Jeremy split up after you caught him cheating.
00:07:40 LISA I —
00:07:45 OFF CAMERA It’s okay. Take your time.
00:07:50 LISA Well yeah he moved back in.
00:07:50 OFF CAMERA Into your new home?
00:07:55 LISA Yeah. What changed that you two decided to get back together?
00:08:00 OFF CAMERA Well he said he was sorry and he begged me. He’s done it before so I took him back.
00:08:10 LISA And how has that been being back with Jeremy?
00:08:15 OFF CAMERA Well I love Jeremy. I do and don’t want to go out and find another boyfriend. I mean we lost 80,000 dollars on that business. And he promised me that he would make it all back.
00:08:30 LISA So is that why you took him back? Has Jeremy continued smoking crack?
00:08:45 OFF CAMERA Yeah a little but he’s not addicted. He says that it calms him down. Me too.
00:09:05 LISA You too?
00:09:05 OFF CAMERA So do you smoke crack with Jeremy?
00:09:15 LISA Yeah we — he made me try it.
00:09:25 [sil.]
00:09:30 [ Crying ]
00:09:40 LISA And then he tried just once. We did it together. [Inaudible] I could.
00:09:55 [ Crying ]
00:10:00 LISA Hit me like a bullet. And it felt so good. I felt so good. And real fast.
00:10:20 [sil.]
00:10:25 LISA Have you ever felt like you were dancing with butterflies?
00:10:30 OFF CAMERA Dancing with butterflies? No I have not.
00:10:40 [sil.]
00:10:45 LISA But he says it’s not addictive, Jeremy.
00:10:50 OFF CAMERA What do you think?
00:10:55 LISA Well I know I can’t get enough.
00:11:00 [ Crying ]
00:11:10 LISA And I know I don’t want to go back to feeling horrible again because when I don’t smoke it I get worse. And when I have it, I feel good. And then it’s gone. And then I know that I’m going to be needing another hit.
00:11:45 OFF CAMERA That sounds a lot like addiction.
00:11:55 LISA Yeah but I know I don’t want it to be.
00:12:00 OFF CAMERA It sounds like you are very scared of getting help and yet at the same very time, it sounds like you know you need that help.
00:12:15 LISA I know I don’t need help. I don’t need anything. Jeremy promised me that everything is going to be okay. And when you love someone like I do, you got to believe him. Right?
00:12:45 [sil.]

Week 8 Substance-Related and Addictive Disorders
Training Title 82
Name: Lisa Pittman
Gender: female
Age: 29 years old
T- 99.8 P- 101 R 20 178/94 Ht 5’6 Wt 140lbs
Background: Lisa is in a West Palm Beach, FL detox facility thinking about long term rehab. She
has been smoking crack cocaine, approximately $100 daily. She admits to cannabis 1–2 times
weekly (“I have a medical card”), and 2–3 alcohol drinks once weekly. She has past drug
possession and theft convictions; currently on 2 yr probation with randomized drug screens.
She tries to find the pattern for the calls in order not to test dirty urine. Her admission labs
abnormal for ALT 168 AST 200 ALK 250; bilirubin 2.5, albumin 3.0; her GGT is 59; UDS positive
for cocaine, THC. Negative for alcohol or other drugs. BAL 0; other labs within normal ranges.
She reports sexual abuse as child ages 5–7, perpetrator being her father who went to prison for
the abuse and drug charges. She is estranged from him. Mother lives in Alabama, hx of anxiety,
benzodiazepine use. Older brother has not contact with family in last 10 years, hx of opioid use.
Sleeps 4-5 hrs, appetite decreased, prefers to get high instead of eating. Allergies: amoxicillin
She is considering treatment for her Hep C+ but needs to get clean first.
Symptom Media. (Producer). (2017). Training title 82 [Video].

Rubric Detail
Create documentation in the Comprehensive Psychiatric Evaluation Template about the patient you selected.
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
18 (18%) – 20 (20%). The response thoroughly 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.
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.
18 (18%) – 20 (20%). The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.
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 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.
23 (23%) – 25 (25%). 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.
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!), 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.).
9 (9%) – 10 (10%). Reflections are thorough, thoughtful, and demonstrate critical thinking.
Provide 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).
14 (14%) – 15 (15%). 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.
Written Expression and Formatting—Paragraph development and organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
5 (5%) – 5 (5%). A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
Paragraphs and sentences follow writing standards for flow, continuity, and clarity.
Written Expression and Formatting—English writing standards:
Correct grammar, mechanics, and punctuation
5 (5%) – 5 (5%). Uses correct grammar, spelling, and punctuation with no errors

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