Comprehensive Psychiatric Evaluation 1

Description

Step 1: You will use the Graduate Comprehensive Psychiatric Evaluation Template Download Graduate Comprehensive Psychiatric Evaluation Templateto:

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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 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…

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.

Grading Rubric

Your assignment will be graded according to the grading rubric Download grading rubric.

The following content is partner providedThe preceding content is partner provided

Rubric

Psychiatric SOAP Note Rubric

Psychiatric SOAP Note Rubric

Criteria Ratings Pts

This criterion is linked to a Learning OutcomeChief Complaint (Reason for seeking health care) – S

4 to >3.0 pts

Exemplary

Includes a direct quote from patient about presenting problem.

3 to >2.0 pts

Distinguished

Includes a direct quote from patient and other unrelated information.

2 to >0.0 pts

Developing

Includes information but information is NOT a direct quote.

0 pts

Novice

Information is completely missing.

4 pts

This criterion is linked to a Learning OutcomeDemographics – S

2 pts

Exemplary

Begins with patient initials, age, race, ethnicity, and gender (5 demographics).

1.5 pts

Distinguished

Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity, and gender).

1 pts

Developing

Begins with 3 or less patient demographics (patient initials, age, race, ethnicity, and gender).

0 pts

Novice

Information is completely missing.

2 pts

This criterion is linked to a Learning OutcomeHistory of the Present Illness (HPI) – S

5 to >3.0 pts

Exemplary

Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity).

3 to >2.0 pts

Distinguished

Includes the presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity).

2 to >1.0 pts

Developing

Includes the presenting problem and 4 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity).

1 to >0 pts

Novice

The presenting problem is not clearly stated and/or there are < 4 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity). 5 pts This criterion is linked to a Learning OutcomeAllergies - S 2 pts Exemplary Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy). 1.5 pts Distinguished If allergies are present, student does not list each type of drug, environmental factor, herbal, food, latex name and include severity of allergy OR description of the allergy. 1 pts Developing If allergies are present, student only lists the type of allergy and omits the name of the allergy. 0 pts Novice Information is completely missing. 2 pts This criterion is linked to a Learning OutcomeReview of Systems (ROS) - S 5 to >3.0 pts

Exemplary

Includes a minimum of 3 assessments for each body system, assesses at least 9 body systems directed to chief complaint, AND uses the words “admits” and “denies.”

3 to >2.0 pts

Distinguished

Includes 3 or fewer assessments for each body system, assesses 5-8 body systems directed to chief complaint, AND uses the words “admits” and “denies.”

2 to >0.0 pts

Developing

Includes 3 or fewer assessments for each body system, and assesses less than 5 body systems directed to chief complaint, OR student does not use the words “admits” and “denies.”

0 pts

Novice

Information is completely missing.

5 pts

This criterion is linked to a Learning OutcomeVital Signs – O

2 pts

Exemplary

Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain).

1.5 pts

Distinguished

Includes at least 6 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain).

1 pts

Developing

Includes at least 4 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain).

0 pts

Novice

Information is completely missing.

2 pts

This criterion is linked to a Learning OutcomeLabs, Diagnostic Tests and Screening Tools – O

3 pts

Exemplary

During the visit: Includes a list of the labs, diagnostic tests or screening tools reviewed at the visit, values of lab results or screening tools, and highlights abnormal values, OR acknowledges no labs/diagnostic tests were reviewed.

2 pts

Distinguished

During the visit: Includes a list of the labs, diagnostic tests, or screening tools reviewed at the visit, but does not include the values of lab results or screening tools, but does not highlight abnormal values.

1 pts

Developing

During the visit: Includes a list of the labs, diagnostic tests, or screening tools reviewed at the visit but does not include the values of the results or highlight abnormal values.

0 pts

Novice

Information is completely missing.

3 pts

This criterion is linked to a Learning OutcomeMedications-S

3 pts

Exemplary

Includes a list of all of the patient reported psychiatric and medical medications and the diagnosis for the medication (including name, dose, route, frequency).

2 pts

Distinguished

Includes a list of all of the patient reported psychiatric and but omits the medical medications and the diagnosis for the medication (including name, dose, route, frequency).

1 pts

Developing

Includes a list of some of the patient reported psychiatric and/or medical medications and the diagnosis for the medication (omits the dose, route, frequency of the medications).

0 pts

Novice

Information is completely missing.

3 pts

This criterion is linked to a Learning OutcomePast Medical History-S

3 pts

Exemplary

Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current.

2 pts

Distinguished

Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current.

1 pts

Developing

Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current.

0 pts

Novice

Information is completely missing.

3 pts

This criterion is linked to a Learning OutcomePast Psychiatric History-S

4 to >3.0 pts

Exemplary

Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), and year of diagnosis.

3 to >2.0 pts

Distinguished

Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (omits addiction treatment), and year of diagnosis.

2 to >0.0 pts

Developing

Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), and does not include the year of diagnosis.

0 pts

Novice

The information is completely missing.

4 pts

This criterion is linked to a Learning OutcomeFamily Psychiatric History-S

4 to >3.0 pts

Exemplary

Includes an assessment of at least 6 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder, and history of suicidal attempts.

3 to >2.0 pts

Distinguished

Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder, and history of suicidal attempts.

2 to >0.0 pts

Developing

Includes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder, and history of suicidal attempts.

0 pts

Novice

Information is completely missing.

4 pts

This criterion is linked to a Learning OutcomeSocial History-S

3 pts

Exemplary

Distinguished Includes all 11 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation.

2 pts

Distinguished

Includes at least 8 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation.

1 pts

Developing

Includes all 6 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation.

0 pts

Novice

Information is completely missing.

3 pts

This criterion is linked to a Learning OutcomeMental Status Exam-O

15 to >12.0 pts

Exemplary

Includes all 10 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with detailed descriptions for each area.

12 to >10.0 pts

Distinguished

Includes all 8 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with detailed descriptions for each area.

10 to >0.0 pts

Developing

Includes >6 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with some descriptions for each area.

0 pts

Novice

Includes <3 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) OR detailed descriptions is not included for each area. 15 pts This criterion is linked to a Learning OutcomePrimary Diagnoses-A 11 to >6.0 pts

Exemplary

Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority) using the DSM-5-TR. The correct ICD-10 billing code is used.

6 to >3.0 pts

Distinguished

Includes a clear outline of the accurate diagnoses addressed at the visit but does not list the diagnoses in descending order of priority using the DSM-5-TR. The correct ICD-10 billing code is used.

3 to >0.0 pts

Developing

Includes an inaccurate diagnosis as the principal diagnosis. The ICD-10 code is incorrect or missing.

0 pts

Novice

Information is completely missing.

11 pts

This criterion is linked to a Learning OutcomeDifferential Diagnoses-A

3 pts

Exemplary

Includes at least 2 differential diagnoses that can be supported by the subjective and objective data provided using the DSM-5-TR. The correct ICD-10 billing code is used.

2 pts

Distinguished

Includes 1 differential diagnosis that can be supported by the subjective and objective data provided using the DSM-5-TR. The correct ICD-10 billing code is used.

1 pts

Developing

Includes at least 1 differential diagnosis that is NOT supported by the subjective and objective data. The ICD-10 code is incorrect or missing.

0 pts

Novice

Information is completely missing.

3 pts

This criterion is linked to a Learning OutcomeOutcome Labs/Screening Tools – O

3 pts

Exemplary

After the visit: orders appropriate diagnostic/lab testing or screening tool 100% of the time OR acknowledges “no diagnostic testing or screening tool clinically required at this time.”

2 pts

Distinguished

After the visit: orders appropriate diagnostic/lab testing 50% of the time OR acknowledges “no diagnostic testing or screening tool clinically required at this time.”

1 pts

Developing

After the visit, orders appropriate diagnostic testing less than 50% of the time.

0 pts

Novice

Information is completely missing.

3 pts

This criterion is linked to a Learning OutcomeTreatment

10 to >8.0 pts

Exemplary

Includes a detailed pharmacologic and non pharmacological treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the following: drug/vitamin/herbal name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. For non-pharmacological treatment, includes: treatment name, frequency, duration. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. The plan is supported by the current US clinical guidelines.

8 to >6.0 pts

Distinguished

Includes a detailed pharmacologic and non pharmacological treatment plan for each of the diagnoses listed under “assessment”. The plan includes 4-7 of the following: drug/vitamin/herbal name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. For non-pharmacological treatment, includes: treatment name, frequency, duration. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. The plan is supported by the current US clinical guidelines.

6 to >0.0 pts

Developing

Includes a detailed pharmacologic and non pharmacological treatment plan for each of the diagnoses listed under “assessment”. The plan includes 4 of the following: drug/vitamin/herbal name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. Non-pharmacological treatment NOT included. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. The plan is NOT supported by the current US clinical guidelines OR is unsafe.

0 pts

Novice

Information is completely missing.

10 pts

This criterion is linked to a Learning OutcomePatient/Family Education-P

5 to >3.0 pts

Exemplary

Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives.

3 to >2.0 pts

Distinguished

Includes at least 2 strategies to promote and develop skills for managing their illness and at least 2 self-management methods on how to incorporate healthy behaviors into their lives.

2 to >0.0 pts

Developing

Includes at least 1 strategies to promote and develop skills for managing their illness and at least 1 self-management methods on how to incorporate healthy behaviors into their lives.

0 pts

Novice

Information is completely missing.

5 pts

This criterion is linked to a Learning OutcomeReferral

3 pts

Exemplary

Provides a detailed list of medical and other interdisciplinary referrals or documents NO REFERRAL ADVISED AT THIS TIME. Includes a timeline for follow up appointments.

2 pts

Distinguished

Provides a medical or other interdisciplinary referral or documents NO REFERRAL ADVISED AT THIS TIME. Includes a timeline for follow up appointments.

1 pts

Developing

Provides a medical or other interdisciplinary referral. DOES NOT include a timeline for follow up appointments.

0 pts

Novice

Information is completely missing.

3 pts

This criterion is linked to a Learning OutcomeAPA Formatting

5 to >3.0 pts

Exemplary

Effectively uses literature and other resources to inform their work. Exceptional use of citations and extended referencing. High level of precision with APA 7th Edition writing style.

3 to >2.0 pts

Distinguished

Effectively uses literature and other resources to inform their work. Moderate use of citations and extended referencing. Moderate level of precision with APA 7th Edition writing style.

2 to >0.0 pts

Developing

Ineffectively uses literature and other resources to inform their work. Moderate use of citations and extended referencing. APA 7th Edition writing style not strictly adhered to.

0 pts

Novice

APA style and writing mechanics not used.

5 pts

This criterion is linked to a Learning OutcomeReferences

5 to >3.0 pts

Exemplary

The reference page contains at least the required current scholarly academic reference and text reference. Follows APA guidelines of components: double space, 12 pt. font, abstract, level headings, hanging indent and in-text citations.

3 to >2.0 pts

Distinguished

References page contains one current scholarly academic resource and text reference. Follows most APA guidelines of components: double space, 12 pt. font, abstract, level headings, hanging indent, and in-text citations.

2 to >0.0 pts

Developing

References page contains one current or outdated scholarly academic resource. Many errors of APA guidelines: double space, 12 pt. font, abstract, level headings, hanging indent, and in-text citations.

0 pts

Novice

References page contains no current scholarly academic resources, only internet webpages or no reference page. Lack of APA guidelines for references provided or in-text citations.

5 pts

Total Points: 100