Description
Step 1: You will use the Graduate Comprehensive Psychiatric Evaluation Template Download Graduate Comprehensive Psychiatric Evaluation Templateto:
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 =
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
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Unformatted Attachment Preview
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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