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…
I can help you with drafting a comprehensive psychiatric evaluation, but since I can’t directly upload files or gather signatures, I’ll guide you through the process and provide a template you can use. Let’s start by organizing the information according to the SOAP note format:
**Subjective (S):**
– Chief Complaint (CC): Describe the patient’s main reason for seeking psychiatric evaluation.
– History of Present Illness (HPI): Provide a detailed account of the presenting problem, using OLDCARTS or PQRST to explore the eight dimensions (Onset, Location, Duration, Characteristics, Aggravating/Alleviating factors, Radiation, Timing, Severity).
– Review of Systems (ROS): Briefly review other symptoms or concerns reported by the patient.
**Objective (O):**
– Medications: List current medications and dosages.
– Allergies: Document any known allergies or adverse drug reactions.
– Past Medical History: Summarize relevant past medical conditions.
– Family Psychiatric History: Note any psychiatric disorders among first-degree relatives.
– Past Surgical History: Mention any previous surgeries.
– Psychiatric History: Provide details of the patient’s psychiatric history, including previous diagnoses, treatments, hospitalizations, and response to therapy.
– Social History: Describe the patient’s social environment, including living situation, relationships, occupation, and substance use.
– Labs and Screening Tools: Include results of relevant laboratory tests or screening assessments.
– Vital Signs: Record vital signs if available.
– Physical Exam: Conduct a focused physical exam, noting any pertinent findings.
– Mental Status Exam: Perform a thorough mental status examination, covering appearance, behavior, speech, mood, affect, thought process, thought content, cognition, insight, and judgment.
**Assessment (A):**
– Primary Diagnosis: Provide a primary psychiatric diagnosis, supported by clinical findings and diagnostic criteria from the DSM-5 and ICD-10.
– Differential Diagnoses: List two differential diagnoses and explain the rationale for each.
– Incorporate current clinical guidelines, research articles, and the role of the PMHNP in the evaluation.
**Plan (P):**
– Pharmacologic Treatment Plan: Outline the proposed pharmacological interventions, including medication selection, dosage, frequency, and monitoring parameters.
– Non-Pharmacologic Treatment Plan: Describe non-pharmacological interventions such as therapy modalities, psychoeducation, and lifestyle modifications.
– Diagnostic Testing/Screening Tools: Specify any additional diagnostic tests or screening tools needed to confirm or rule out differential diagnoses.
– Patient/Family Teaching: Provide education to the patient and family regarding the diagnosis, treatment options, prognosis, and self-management strategies.
– Referral and Follow-Up: Recommend referrals to other healthcare providers or specialists as needed and establish a follow-up plan to monitor progress and adjust treatment accordingly.
I recommend reviewing the Graduate Comprehensive Psychiatric/Psychotherapy Evaluation Template and incorporating the required elements into your evaluation. Once completed, you can present it to your preceptor for review and signature. Let me know if you need further assistance with drafting the evaluation or if you have any specific questions!
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