Step 1: You will use the Graduate Comprehensive Psychiatric/Psychotherapy Evaluation Template Download Graduate Comprehensive Psychiatric/Psychotherapy Evaluation Template to:
Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.
Upload your completed comprehensive psychiatric evaluation as a Word doc. Scanned PDFs will not be accepted.
For the Comprehensive Evaluation Presentation Assignment: You will need to get it signed by your preceptor for the presentation (actual signature, not electronically typed).
Step 2: Each student will create a focused SOAP note video presentation in the next assignment. See Comprehensive Evaluation Presentation 1 for more details.
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.
S =
Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS)
O =
Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam, (Focused), and Mental Status Exam
A =
Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes
P =
Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up
Other: Incorporate current clinical guidelines NIH Clinical GuidelinesLinks to an external site. or APA Clinical GuidelinesLinks to an external site., research articles, and the role of the PMHNP in your evaluation.
Psychiatric Assessment of Infants and ToddlersLinks to an external site.
Psychiatric Assessment of Children and AdolescentsLinks to an external site.
Reminder: It is important that you complete this assessment using your critical thinking skills. You are expected to synthesize your clinical assessment, formulate a psychiatric diagnosis, and develop a treatment plan independently. It is not acceptable to document “my preceptor made this diagnosis.” An example of the appropriate descriptors of the clinical evaluation is listed below. It is not acceptable to document “within normal limits.”
Graduate Mental Status Exam Guide Download Graduate Mental Status Exam Guide
Successfully Capture HPI Elements in Psychiatry E/M NotesLinks to an external site.
AAPC Admin. (2013, August 1). Successfully capture HPI elements in psychiatry E/M notes. Advancing the Business of Healthcare. https://www.aapc.com/blog/25848-successfully-captu…
Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.
Comprehensive Psychiatric Evaluation Template
With Psychotherapy Note
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
SI/HI: _______________________________________________________________________________
Sleep: _________________________________________ Appetite: ________________________
Allergies (Drug/Food/Latex/Environmental/Herbal): ___________________________________
Current perception of Health: Excellent Good Fair Poor
Psychiatric History:
Inpatient hospitalizations:
Date
Hospital
Diagnoses
Length of Stay
Outpatient psychiatric treatment:
Date
Hospital
Diagnoses
Length of Stay
Detox/Inpatient substance treatment:
Date
Hospital
Diagnoses
Length of Stay
History of suicide attempts and/or self injurious behaviors: ____________________________________
Past Medical History
Major/Chronic Illnesses____________________________________________________
Trauma/Injury ___________________________________________________________
Hospitalizations __________________________________________________________
Past Surgical History___________________________________________________________
Current psychotropic medications:
_________________________________________ ________________________________
_________________________________________ ________________________________
_________________________________________ ________________________________
Current prescription medications:
_________________________________________ ________________________________
_________________________________________ ________________________________
_________________________________________ ________________________________
OTC/Nutritionals/Herbal/Complementary therapy:
_________________________________________ ________________________________
_________________________________________ ________________________________
Substance use: (alcohol, marijuana, cocaine, caffeine, cigarettes)
Substance
Amount
Frequency
Length of Use
Family Psychiatric History: _____________________________________________________
Social History
Lives: Single family House/Condo/ with stairs: ___________ Marital Status:________
Education:____________________________
Employment Status: ______ Current/Previous occupation type: _________________
Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________
Sexual Orientation: _______ Sexual Activity: ____ Contraception Use: ____________
Family Composition: Family/Mother/Father/Alone: _____________________________
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________
________________________________________________________________________
Health Maintenance
Screening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, Dementia
Exposures:
Immunization HX:
Review of Systems (at least 3 areas per system):
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
Physical Exam
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (percentile) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
Mental Status Exam
Appearance:
Behavior:
Speech:
Mood:
Affect:
Thought Content:
Thought Process:
Cognition/Intelligence:
Clinical Insight:
Clinical Judgment:
Psychotherapy Note
Therapeutic Technique Used:
Session Focus and Theme:
Intervention Strategies Implemented:
Evidence of Patient Response:
Plan:
Differential Diagnoses
1.
2.
Principal Diagnoses
1.
2.
Plan:
Diagnosis #1
Diagnostic Testing/Screening:
Pharmacological Treatment:
Non-Pharmacological Treatment:
Patient/Family Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Diagnosis #2
Diagnostic Testing/Screening Tool:
Pharmacological Treatment:
Non-Pharmacological Treatment:
Patient/Family Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Signature (with appropriate credentials): __________________________________________
Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________
DEA#: 101010101 STU Clinic LIC# 10000000
Tel: (000) 555-1234 FAX: (000) 555-12222
Patient Name: (Initials)______________________________ Age ___________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________ Refill: _________________
No Substitution
Signature: ____________________________________________________________
**Comprehensive Psychiatric Evaluation**
Encounter date: [Date]
Patient Initials: [Initials] Gender: [M/F/Transgender] Age: [Age] Race: [Race] Ethnicity: [Ethnicity]
**Reason for Seeking Health Care:** [Reason for seeking health care]
**History of Present Illness (HPI):** [Detailed history of present illness including symptoms, onset, duration, exacerbating/alleviating factors]
**Suicidal Ideation/Homicidal Ideation (SI/HI):** [Presence or absence of suicidal or homicidal ideation]
**Sleep:** [Description of sleep patterns]
**Appetite:** [Description of appetite]
**Allergies:** [List of drug/food/latex/environmental/herbal allergies]
**Current Perception of Health:** [Excellent/Good/Fair/Poor]
**Psychiatric History:**
**Inpatient Hospitalizations:**
– Date: [Date] Hospital: [Hospital] Diagnoses: [Diagnoses] Length of Stay: [Length of Stay]
**Outpatient Psychiatric Treatment:**
– Date: [Date] Hospital: [Hospital] Diagnoses: [Diagnoses] Length of Stay: [Length of Stay]
**Detox/Inpatient Substance Treatment:**
– Date: [Date] Hospital: [Hospital] Diagnoses: [Diagnoses] Length of Stay: [Length of Stay]
**History of Suicide Attempts and/or Self-Injurious Behaviors:** [Description of past suicide attempts or self-injurious behaviors]
**Past Medical History:**
– Major/Chronic Illnesses: [List of major/chronic illnesses]
– Trauma/Injury: [Description of trauma or injury]
– Hospitalizations: [List of past hospitalizations]
**Past Surgical History:** [Description of past surgical procedures]
**Current Psychotropic Medications:**
– [Medication 1]
– [Medication 2]
– [Medication 3]
**Current Prescription Medications:**
– [Medication 1]
– [Medication 2]
– [Medication 3]
**OTC/Nutritionals/Herbal/Complementary Therapy:**
– [Therapy 1]
– [Therapy 2]
**Substance Use:**
– [Substance 1]
– [Substance 2]
– [Substance 3]
**Family Psychiatric History:** [Description of family psychiatric history]
**Social History:**
– Lives: [Living situation]
– Marital Status: [Marital status]
– Education: [Education level]
– Employment Status: [Employment status]
– Sexual Orientation: [Sexual orientation]
– Sexual Activity: [Description of sexual activity]
– Contraception Use: [Description of contraception use]
– Family Composition: [Description of family composition]
– Other: [Additional relevant social history]
**Health Maintenance:**
– Screening Tests: [List of screening tests]
– Exposures: [Description of exposures]
– Immunization HX: [Immunization history]
**Review of Systems:** [Description of review of systems]
**Physical Exam:**
– BP: [Blood pressure] TPR: [Temperature, pulse, respiration] HR: [Heart rate] RR: [Respiratory rate] Ht.: [Height] Wt.: [Weight] BMI: [Body mass index]
– [Detailed description of physical exam findings]
**Mental Status Exam:**
– [Description of appearance, behavior, speech, mood, affect, thought content, thought process, cognition/intelligence, clinical insight, clinical judgment]
**Psychotherapy Note:**
– Therapeutic Technique Used: [Therapeutic technique]
– Session Focus and Theme: [Focus and theme of session]
– Intervention Strategies Implemented: [Intervention strategies]
– Evidence of Patient Response: [Description of patient response]
**Assessment:**
**Differential Diagnoses:**
[Diagnosis 1]
[Diagnosis 2]
**Principal Diagnoses:**
[Principal Diagnosis 1]
[Principal Diagnosis 2]
**Plan:**
**Diagnosis #1**
– Diagnostic Testing/Screening: [Description of testing/screening]
– Pharmacological Treatment: [Description of pharmacological treatment]
– Non-Pharmacological Treatment: [Description of non-pharmacological treatment]
– Patient/Family Education: [Description of education provided to patient/family]
– Referrals: [Referrals made]
– Follow-up: [Description of follow-up plan]
– Anticipatory Guidance: [Anticipatory guidance provided]
**Diagnosis #2**
– Diagnostic Testing/Screening Tool: [Description of testing/screening]
– Pharmacological Treatment: [Description of pharmacological treatment]
– Non-Pharmacological Treatment: [Description of non-pharmacological treatment]
– Patient/Family Education: [Description of education provided to patient/family]
– Referrals: [Referrals made]
– Follow-up: [Description of follow-up plan]
– Anticipatory Guidance: [Anticipatory guidance provided]
**Signature (with appropriate credentials):** [Signature]
**Cite current evidenced-based guideline(s) used to guide care:** [Citation of guidelines used]
DEA#: [DEA number] STU Clinic
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