Step 1: You will use the Graduate Comprehensive Psychiatric Evaluation Template Download Graduate Comprehensive Psychiatric 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 Psychiatric 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 Psychiatric Evaluation Presentation 2
for more details.
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.
| S = |
| O = |
| A = | P = |
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…
Submission Instructions:
- Upload your completed Comprehensive Psychiatric Evaluation as a word document. It will be assessed through Turnitin.
- Complete and submit the assignment by 11:59 PM ET Sunday.
Psychiatric SOAP Note Template
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:
Date
Date
Hospital
Inpatient hospitalizations:
Diagnoses
Length of Stay
Hospital
Outpatient psychiatric treatment:
Diagnoses
Length of Stay
Rev. 10162021 LM
Date
Hospital
Detox/Inpatient substance treatment:
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:
_________________________________________
_________________________________________
________________________________
________________________________
Rev. 10162021 LM
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: _____________________________
Rev. 10162021 LM
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx,
trauma, violence, social network, marital hx):_________________________________
________________________________________________________________________
Health Maintenance
Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____
Exposures:
Immunization HX:
Review of Systems:
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Rev. 10162021 LM
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:
Rev. 10162021 LM
Musculoskeletal:
Derm:
Psychosocial:
Misc.
Mental Status Exam
Appearance:
Behavior:
Speech:
Mood:
Affect:
Thought Content:
Thought Process:
Cognition/Intelligence:
Clinical Insight:
Clinical Judgment:
Rev. 10162021 LM
Significant Data/Contributing
Dx/Labs/Misc.
Plan:
Differential Diagnoses
1.
2.
Principal Diagnoses
1.
2.
Plan
Diagnosis #1
Diagnostic Testing/Screening:
Pharmacological Treatment:
Non-Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Rev. 10162021 LM
Anticipatory Guidance:
Diagnosis #2
Diagnostic Testingg/Screenin:
Pharmacological Treatment:
Non-Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Signature (with appropriate credentials): __________________________________________
Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________
Rev. 10162021 LM
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: ____________________________________________________________
Rev. 10162021 LM
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Turnitin Report
Formatting
Title Page
Citation
Outline
