Description
You will use the: Graduate Comprehensive Psychiatric Evaluation Template
Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.
Your preceptor MUST sign their initials on the comprehensive psychiatric evaluation document to confirm they have reviewed and acknowledge this patient was seen in their clinic.
You will then use Canvas Studio Screen Capture and Webcam (I want to see your face and your document at the same time) to record yourself presenting your completed comprehensive psychiatric evaluation document.
Use?ONLY Canvas Studio to record your comprehensive psychiatric evaluation and verbal presentation. No other medium will be accepted.
How do I record a Canvas Studio video with a webcam in a course?
How do I create a video with a PowerPoint in Canvas Studio Screen Capture
Step 2: Each student will create a focused SOAP note PowerPoint presentation. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive psychiatric SOAP note is to be written using the attached template below.
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 Guidelines or APA Clinical Guidelines, research articles, and the role of the PMHNP in your presentation.
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 synthesis 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…MENTAL STATUS EXAM GUIDE
Previous Mental Health Treatments (e g: psychopharmacology, inpatient stabilization, Occupational
Therapy, Vocational Therapy, Marriage/Family Therapy, Group Therapy, Detox, ECT &/or social
services):
What is the initial impression of the admitting examiner found in the initial evaluation, triage, or social
worker note:
Compare your impression of the patient’s status now to the initial impression:
BRIEF MENTAL STATUS EXAM
Instructions; Most information can be obtained during an interaction with the patient without asking
specific questions. The information must be described to support your conclusion.
GENERAL DESCRIPTION
Appearance (e.g. grooming, manner of dress, level of hygiene, facial expression, remarkable
features, height, weight, nutritional status, presence of piercings, tattoos, scars, the relationship
between appearance and age, etc.):
Attitude toward examiner (INCLUDED IN BEHAVIOR) – Does the patient have good eye contact?
Are they cooperative, friendly, attentive, interested, frank, seductive, defensive, playful, apathetic,
evasive, guarded, etc.:
Speech characteristic –
What are the qualities of the patient’s speech include tone, inflection, volume, pronunciation
(clear or slurred; mumbling; defects, lisp, stuttering), speed:
What is the quantity of the patient’s speech? Does the patient verbalizes freely, provide
monosyllabic answers, have pressured speech, and/or are they hyperverbal:
Psychomotor activity (INCLUDED IN BEHAVIOR)
Is the patient experiencing hypoactive psychomotor activity that can include generalized
slowing down of body movements, aimless, purposeless activity, etc.? Write your description
and conclusion:
Is the patient experiencing hyperactive psychomotor activity that can include restlessness,
agitation, combativeness, wringing of hands, pacing, etc.? Write your description and
conclusion:
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MOOD/AFFECT
Mood – is the sustained/consistent emotion that colors their perception of the word.
Is the patient’s mood sad, labile, euphoric, euthymic, expansive, anhedonic, etc.
Is the patient anxious, angry and/or depressed? Assess for mild, moderate, or severe and
document findings that support your conclusion.
IMPORTANT: Ask the patient if they are having any suicidal or homicidal thoughts, if the patient indicates
in any way that they, then ask them if they have a plan and report these findings to the staff immediately
so measures can be taken to safeguard the patient.
Affect – Patient’s current emotional reaction that is being inferred from the patient’s facial expression.
What is the range of the patient’ affect (full or restricted)? What findings support your
conclusion:
Is the patient’s affect appropriate; is the emotional expression congruent with the thought
content? What findings support your conclusion:
Is the intensity of the patient’s affect blunted or flat, shallow, labile, proud, angry, fearful,
anxious, guilty, etc.? What findings support your conclusion:
Does the patient have difficulty in initiating, sustaining, or terminating an emotional response?
What findings support your conclusion:
DISORDERS OF THE FORM OF THOUGHT
The thought process refers to the way a person puts together ideas and associations. Is the patient
disorganized, coherent, has a flight of ideas, though blocking, tangential, circumstantial, rambling,
evasive? Is there a lack of cause and effect relationship and goal-directed thinking:
Thought content refers to what the person is thinking and speaking about. Does the patient have
preoccupations: about illness, environmental problems, obsessions, compulsions, phobias;
obsessions about suicide, homicide, hypochondriacal symptoms, and specific antisocial urges:
IMPORTANT: Ask the patient if they are having any suicidal or homicidal thoughts, if the patient indicates
in any way that they, then ask them if they have a plan and report these findings to the staff immediately
so measures can be taken to safeguard the patient.
Does the patient’s thought content contain delusional material? If yes, describe the types of
delusion(s)? Include in your description details about the extent and nature of the delusions:
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PERCEPTION (INCLUDED IN THOUGHT CONTENT)
Hallucinations are a form of disturbance of the sensory system. To determine if someone is
experiencing them you can the person “Have you ever heard voices or sounds that no one else can”?
“Smelled something that no one else can?” “Felt like bugs were crawling all over you?” “Seen
something that no one else can see?” Include in your description details about the extent and nature
of the hallucination and how you reached this conclusion:
Illusions are a misperception of a person-environment such as an exit sign that looks like the devil.
COGNITION
Orientation
Person:
Place:
Time:
Is the patient’s orientation good, fair or poor; support your conclusion:
Memory functions are usually divided into remote memory, recent past memory, recent memory and
immediate retention and recall.
Remote – Can the patient provide childhood data; important events: time and place of birth;
various schools attended; number of children and ages and names. Is the patient’s remote
memory good, fair or poor; support your conclusion:
Recent Past Memory – Can the patient tell you what they did yesterday, what did they have for
breakfast, lunch, dinner? Is the patient’s recent past memory good, fair or poor; support your
conclusion:
Tell the patient that you are going to ask them to repeat the three words you are going to tell
them, pen, apple, watch. After the patient is finished, remind him/her that you will be asking
them these in a few minutes,
Recall /Immediate Retention Memory – Ask the patient to repeat the three word you have just
finished saying. Is the patient’s recent memory good, fair or poor; support your conclusion:
Recent Memory – Ask the patient to repeat the three words you told them a few minutes ago. Is
the patient’s recent memory good, fair or poor; support your conclusion:
Concentration and attention is the ability to remain focused. Is the patient’s attention span good,
slight, moderate or severely distractible?
3
Abstract/Concrete thinking is the ability to deal with concepts. Proverbs or “similarities” can determine
if the patient is an abstract or concrete thinker. Ask “What do people generally mean when they say…
Don’t count your chickens before they’re hatched?”. When using similarities, ask, “In what ways are
an apple and a banana alike?” Is the patient’s ability to abstract good, fair or poor; support your
conclusion:
JUDGMENT AND INSIGHT
Judgment is the patient’s understanding of socially conforming behavior and the ability to understand
the outcome of their behavior. If you are not aware of the patient’s judgment as what is the thing to
do if you are the first person in the theatre to discover a fire and/or what will you do when you are
discharged from the hospital. Is the patient’s judgment good, fair, poor; support your conclusion.
Insight is the patient’s awareness of the illness and the understanding of the outcome. Is the patient’s
insight good, fair, poor; support your conclusion:
BIOLOGICAL DATA
Oxygenation:
Respiration: (Quality and quantity):
Temp:
B/P:
Pulse: (Quality and quantity):
Metabolism
Ingestion includes the patient’s nutritional intake. How many times does he/she eat full meals
or snacks per day? What do the meal and snack consist of, is the patient on a specific diet,
and is the patient’s report congruent with the diet limitations:
Digestion includes gas/burping, reflux, acid indigestion, nausea/vomiting, pain, ulcer, bloating,
etc. Does the patient have any digestion difficulties?
Elimination includes gas/flatulence, diarrhea, loose stools, constipation, etc. How many
BMs/day? Is the consistency normal? Is there any blood in the stool:
Sleep Patterns
Quality – Does the patient have difficulty falling asleep or falling back to sleep? Are they tired
upon awakening? Do they have early morning awakening, bad dreams, and nightmares? Do
they wet the bed, walking in sleep, etc.:
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Quantity – How many hours of sleep does the patient need to feel good in the morning? How many
hours of sleep do they get now? What time do you go to sleep & wake up:
SOCIAL HISTORY
Support system: (Is there support from family, friends, church, work, etc.):
Occupation – (Any job in the past or present, employee or volunteer; would the patient like to have a
job, what would that job be):
Spiritual Assessment
What importance does religion/spirituality have in the patient’s life:
Do the patient’s beliefs help with stressful situations:
Education – What was the highest level of school completed; any vocational training programs
attended; would the patient like to go back to school or vocational training:
Financial Support – who works in the household; what other means of financial support is there for the
household:
Interests – What does the patient do in their spare time (e.g. watch TV; exercise; fishing; woodcraft;
reading; theatre; movies; bowling; walking; running; crossword puzzles etc.):
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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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