Step 1: You will use the
Graduate Comprehensive Psychotherapy Evaluation Template
Download Graduate Comprehensive Psychotherapy Evaluation Template
to:
Compose a written comprehensive psychotherapy evaluation of a patient you have seen in the clinic.
Upload your completed comprehensive psychotherapy evaluation as a Word doc. Scanned PDFs will not be accepted.
For the Comprehensive Psychotherapy 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 Psychotherapy Evaluation Presentation 3
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 =
Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up
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…
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