Comprehensive Psychiatric and/or Psychotherapy Evaluation 3 Step 1: You will use the Graduate Comprehensive Psychiatric/Psychotherapy Evaluation Template Download Graduate Comprehensive
Comprehensive Psychiatric and/or Psychotherapy Evaluation 3
Step 1: You will use the Graduate Comprehensive Psychiatric/Psychotherapy Evaluation Template Download Graduate Comprehensive Psychiatric/Psychotherapy Evaluation Templateto:
1. Compose a written comprehensive psychotherapy evaluation of a patient you have seen in the clinic.
2. Upload your completed comprehensive psychiatric evaluation as a Word doc. Scanned PDFs will not be accepted.
· For the Comprehensive 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 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-capture-hpi-elements-in-psychiatry-em-notes/
Submission Instructions:
· Upload your completed Comprehensive Psychiatric/Psychotherapy Evaluation as a word document. It will be assessed through Turnitin.
· Complete and submit the assignment by 11:59 PM ET Thursday.
· Psychiatric/Psychotherapy SOAP Note Rubric
|
Criteria |
Ratings |
Points |
|||
|
Chief
Complaint (Reason for seeking health care) - S |
4 to
>3.0 points Exemplary Includes
a direct quote from patient about presenting problem. |
3 to
>2.0 points Distinguished Includes
a direct quote from patient and other unrelated information. |
2 to
>0.0 points Developing Includes
information but information is NOT a direct quote. |
0 points Novice Information
is completely missing. |
4 points |
|
Demographics
- S |
2 points Exemplary Begins with patient initials, age,
race, ethnicity, and gender (5 demographics). |
1.5 points Distinguished Begins with 4 of the 5 patient
demographics (patient initials, age, race, ethnicity, and gender). |
1 points Developing Begins with 3 or less patient demographics
(patient initials, age, race, ethnicity, and gender). |
0 points Novice Information is completely missing. |
2 points |
|
History
of the Present Illness (HPI) - S |
5 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). |
3 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 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). |
1 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). |
5 points |
|
Allergies
- S |
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). |
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. |
0 points Novice Information is completely missing. |
2 points |
|
Review
of Systems (ROS) - S |
5 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.” |
3 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 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.” |
0 points Novice Information is completely missing. |
5 points |
|
Vital
Signs - O |
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). |
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). |
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). |
0 points Novice Information
is completely missing. |
2 points |
|
Labs,
Diagnostic Tests and Screening Tools - O |
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. |
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 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. |
3 points |
|
Medications-S |
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). |
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). |
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). |
0 points Novice Information is completely missing. |
3 points |
|
Past
Medical History-S |
3 points Exemplary Includes (Major/Chronic, Trauma,
Hospitalizations), for each medical diagnosis, year of diagnosis and whether
the diagnosis is active or current. |
2 points Distinguished Includes (Major/Chronic, Trauma,
Hospitalizations), for each medical diagnosis, either year of diagnosis OR
whether the diagnosis is active or current. |
1 points Developing Includes each medical diagnosis but
does not include year of diagnosis or whether the diagnosis is active or
current. |
0 points Novice Information is completely missing. |
3 points |
|
Past
Psychiatric History-S |
4 3.0 points Exemplary Includes (Outpatient and Hospitalizations),
for each psychiatric diagnosis (including addiction treatment), and year of
diagnosis. |
3 2.0 points Distinguished Includes (Outpatient and
Hospitalizations), for each psychiatric diagnosis (omits addiction
treatment), and year of diagnosis. |
2 0.0 points Developing Includes (Outpatient and
Hospitalizations), for each psychiatric diagnosis (including addiction
treatment), and does not include the year of diagnosis. |
0 points Novice The information is completely missing. |
4 points |
|
Family
Psychiatric History-S |
4 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 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 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. |
0 points Novice Information is completely missing. |
4 points |
|
Social
History-S |
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. |
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. |
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. |
0 points Novice Information is completely missing. |
3 points |
|
Mental
Status Exam-O |
15 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. |
12 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. |
10 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. |
0 points 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 points |
|
Primary
Diagnoses-A |
11 6.0 points Exemplary Includes a clear outline of the
accurate principal diagnosis using DSM-5-TR critieria AND lists the remaining
diagnoses addressed at the visit (in descending priority). The correct ICD-10
billing code is used. |
6 3.0 points Distinguished Includes a clear outline of the
accurate diagnoses using DSM-5-TR criteria addressed at the visit but does
not list the diagnoses in descending order of priority. The correct ICD-10
billing code is used. |
3 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. |
11 points |
|
Differential
Diagnoses-A |
3 points Exemplary Includes at least 2 differential
diagnoses that can be supported by the subjective and objective data provided
and are accurate based on DSM-5-TR critieria. The 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 and are
accurate based on DSM-5-TR criteria. 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. |
3 points |
|
Outcome
Labs/Screening Tools - O |
3 points 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 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. |
3 points |
|
Treatment |
10 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 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 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 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 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. |
10 points |
|
Patient/Family
Education-P |
5 3.0 points 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 2.0 points 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 0.0 points 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 points Novice Information is completely missing. |
5 points |
|
Referral |
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. |
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. |
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 points |
|
APA
Formatting |
5 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. |
3 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. |
2 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. |
5 points |
|
References |
5 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 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 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 |
·