Posted: February 18th, 2023

Comprehensive Psychiatric Evaluation and SOAP Note Development

Comprehensive Psychiatric Evaluation 3

Step 1: You will use the Graduate Comprehensive Psychiatric Evaluation Template ,I, to:

Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.
Ensure that your evaluation reflects a thorough understanding of the patient’s psychiatric condition.
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).
Remember, the quality of your documentation can significantly impact your clinical evaluation.
Step 2: Each student will create a focused SOAP note video presentation in the next assignment.

Ensure your presentation is clear, concise, and adheres to the SOAP format.
See Comprehensive Psychiatric Evaluation Presentation 3 for more details.
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.
Understanding and applying this framework correctly is crucial for effective patient management.
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

Collecting accurate and comprehensive data in these areas is vital for a correct diagnosis.
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

Your assessment and plan should be evidence-based, reflecting the latest clinical guidelines.
Other: Incorporate current clinical guidelines NIH Clinical Guidelines or APA Clinical Guidelines n+, research articles, and the role of the PMHNP in your evaluation.

Staying updated with clinical guidelines ensures your practice is current and effective.
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!’

Demonstrate your clinical decision-making skills by independently interpreting data.
An example of the appropriate descriptors of the clinical evaluation is listed below. It is not acceptable to document “within normal limits.”
Detailed and specific observations enhance the credibility of your evaluation.
Graduate Mental Status Exam Guide ,I,

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-capture-hpi-elements-in-psychiatry-em-notes/

Psychiatric SOAP Note Rubric

Psychiatric Evaluation: A Comprehensive Guide for PMHNPs”

References:

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5). American Psychiatric Publishing.
Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 10th ed. Wolters Kluwer.
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Tags: Clinical Guidelines, Mental Status Exam, PMHNP, Psychiatric Evaluation, Soap Note