Step 1: You will use the
Graduate Comprehensive 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 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 1
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 Guidelines
or
APA Clinical Guidelines
, research articles, and the role of the PMHNP in your evaluation.
- Psychiatric Assessment of Infants and Toddlers
Psychiatric Assessment of Children and Adolescents
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
Successfully Capture HPI Elements in Psychiatry E/M Notes
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 Psychotherapy 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
.
Comprehensive Psychiatric Evaluation Template
With Psychotherapy Note
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
Hospital
Inpatient hospitalizations:
Diagnoses
Length of Stay
Date
Hospital
Outpatient psychiatric treatment:
Diagnoses
Length of Stay
Rev. 2272022 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. 2272022 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: _____________________________
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx,
trauma, violence, social network, marital hx):_________________________________
________________________________________________________________________
Rev. 2272022 LM
Health Maintenance
Screening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism,
Psychosis, Dementia
Exposures:
Immunization HX:
Review of Systems (at least 3 areas per system):
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Rev. 2272022 LM
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:
Musculoskeletal:
Derm:
Rev. 2272022 LM
Psychosocial:
Misc.
Mental Status Exam
Appearance:
Behavior:
Speech:
Mood:
Affect:
Thought Content:
Thought Process:
Cognition/Intelligence:
Clinical Insight:
Clinical Judgment:
Rev. 2272022 LM
Psychotherapy Note
Therapeutic Technique Used:
Session Focus and Theme:
Intervention Strategies Implemented:
Evidence of Patient Response:
Plan:
Differential Diagnoses
1.
2.
Principal Diagnoses
1.
2.
Plan:
Diagnosis #1
Diagnostic Testing/Screening:
Pharmacological Treatment:
Non-Pharmacological Treatment:
Rev. 2272022 LM
Patient/Family Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Diagnosis #2
Diagnostic Testing/Screening Tool:
Pharmacological Treatment:
Non-Pharmacological Treatment:
Patient/Family Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Signature (with appropriate credentials): __________________________________________
Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________
Rev. 2272022 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. 2272022 LM
Psychiatric SOAP Note Rubric
Criteria
Chief Complaint
(Reason for
seeking health
care) – S
Demographics S
History of the
Present Illness
(HPI) – S
Allergies – S
Review of
Systems (ROS) S
Ratings
4 to >3.0 points
Exemplary
Includes a direct
quote from patient
about presenting
problem.
2 points
Exemplary
Begins with patient
initials, age, race,
ethnicity, and gender
(5 demographics).
5 to >3.0 points
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).
2 points
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).
5 to >3.0 points
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.”
Points
3 to >2.0 points
Distinguished
Includes a direct
quote from patient
and other unrelated
information.
1.5 points
Distinguished
Begins with 4 of the 5
patient demographics
(patient initials, age,
race, ethnicity, and
gender).
3 to >2.0 points
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 >0.0 points
Developing
Includes information
but information is
NOT a direct quote.
0 points
Novice
Information is
completely
missing.
1 points
Developing
Begins with 3 or less
patient demographics
(patient initials, age,
race, ethnicity, and
gender).
2 to >1.0 points
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).
0 points
Novice
Information is
completely
missing.
1.5 points
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 points
Developing
If allergies are
present, student only
lists the type of
allergy and omits the
name of the allergy.
3 to >2.0 points
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 points
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.”
1 to >0 points
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).
0 points
Novice
Information is
completely
missing.
4
points
2
points
5
points
2
points
0 points
Novice
Information is
completely
missing.
5
points
Vital Signs - O
Labs, Diagnostic
Tests and
Screening Tools O
Medications-S
Past Medical
History-S
Past Psychiatric
History-S
2 points
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).
3 points
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.
3 points
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).
1.5 points
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).
2 points
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 points
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).
1 points
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 points
Novice
Information is
completely
missing.
2 points
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).
0 points
Novice
Information is
completely
missing.
3 points
Exemplary
Includes
(Major/Chronic,
Trauma,
Hospitalizations), for
each medical
diagnosis, year of
diagnosis and
whether the
diagnosis is active or
current.
4 to >3.0 points
Exemplary
Includes (Outpatient
and Hospitalizations),
for each psychiatric
diagnosis (including
2 points
Distinguished
Includes
(Major/Chronic,
Trauma,
Hospitalizations), for
each medical
diagnosis, either year
of diagnosis OR
whether the
diagnosis is active or
current.
3 to >2.0 points
Distinguished
Includes (Outpatient
and Hospitalizations),
for each psychiatric
diagnosis (omits
1 points
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).
1 points
Developing
Includes each medical
diagnosis but does
not include year of
diagnosis or whether
the diagnosis is active
or current.
2 to >0.0 points
Developing
Includes (Outpatient
and Hospitalizations),
for each psychiatric
diagnosis (including
0 points
Novice
The information is
completely
missing.
2
points
0 points
Novice
Information is
completely
missing.
3
points
3
points
0 points
Novice
Information is
completely
missing.
3
points
4
points
Family
Psychiatric
History-S
Social History-S
Mental Status
Exam-O
Primary
Diagnoses-A
addiction treatment),
and year of diagnosis.
addiction treatment),
and year of diagnosis.
4 to >3.0 points
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 points
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.
15 to >12.0 points
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.
3 to >2.0 points
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 points
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.
12 to >10.0 points
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.
11 to >6.0 points
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.
6 to >3.0 points
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
addiction treatment),
and does not include
the year of diagnosis.
2 to >0.0 points
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.
1 points
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.
10 to >0.0 points
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.
3 to >0.0 points
Developing
Includes an
inaccurate diagnosis
as the principal
diagnosis. The ICD-10
code is incorrect or
missing.
0 points
Novice
Information is
completely
missing.
4
points
0 points
Novice
Information is
completely
missing.
3
points
0 points
Novice
Includes 8.0 points
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 nonpharmacological
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.
correct ICD-10 billing
code is used.
2 points
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 points
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 points
Novice
Information is
completely
missing.
2 points
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 points
Developing
After the visit, orders
appropriate
diagnostic testing less
than 50% of the time.
0 points
Novice
Information is
completely
missing.
8 to >6.0 points
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 nonpharmacological
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 points
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 points
Novice
Information is
completely
missing.
3
points
3
points
10
points
Patient/Family
Education-P
Referral
APA Formatting
References
5 to >3.0 points
Exemplary
Includes at least 3
strategies to promote
and develop skills for
managing their illness
and at least 3 selfmanagement
methods on how to
incorporate healthy
behaviors into their
lives.
3 points
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.
5 to >3.0 points
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.
5 to >3 points
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 points
Distinguished
Includes at least 2
strategies to promote
and develop skills for
managing their illness
and at least 2 selfmanagement
methods on how to
incorporate healthy
behaviors into their
lives.
2 points
Distinguished
Provides a medical or
other
interdisciplinary
referral or documents
NO REFERRAL
ADVISED AT THIS
TIME. Includes a
timeline for follow up
appointments.
2 to >0.0 points
Developing
Includes at least 1
strategies to promote
and develop skills for
managing their illness
and at least 1 selfmanagement
methods on how to
incorporate healthy
behaviors into their
lives.
1 points
Developing
Provides a medical or
other
interdisciplinary
referral. DOES NOT
include a timeline for
follow up
appointments.
0 points
Novice
Information is
completely
missing.
3 to >2.0 points
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.
3 to >2 points
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 points
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 points
Novice
APA style and
writing mechanics
not used.
2 to >0 points
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 points
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
points
0 points
Novice
Information is
completely
missing.
3
points
5
points
5
points
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