Comprehensive Psychiatric Evaluation 1 Step 1: You will use the Graduate Comprehensive Psychiatric Evaluation Template Download Graduate Comprehensive Psychiatric Evaluation Templateto: 1. Compose
Comprehensive Psychiatric Evaluation 1
Step 1: You will use the Graduate Comprehensive Psychiatric Evaluation Template Download Graduate Comprehensive Psychiatric Evaluation Templateto:
1. Compose a written comprehensive psychiatric 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 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 1 for more details.
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.
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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) |
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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 |
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A = |
Assessment: Primary Diagnosis and two differential diagnoses including
ICD-10 and DSM5 codes |
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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 Evaluation as a word document. It will be assessed through Turnitin.
· Complete and submit the assignment by 11:59 PM ET Thursday.
Grading Rubric
Your assignment will be graded according to the grading rubric Download grading rubric.
View Rubric
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Psychiatric SOAP Note
Rubric |
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Psychiatric SOAP Note
Rubric |
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Criteria |
Ratings |
Pts |
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Chief Complaint
(Reason for seeking health care) - S |
4 to >3 pts Exemplary Includes a direct quote from patient
about presenting problem. 3 to >2 pts Distinguished Includes a direct quote from patient
and other unrelated information. 2 to >0 pts Developing Includes information but information
is NOT a direct quote. 0 pts Novice Information is completely missing. |
/ 4 pts |
|
Demographics - 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 |
|
History of the Present
Illness (HPI) - S |
5 to >3 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 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 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 |
|
Allergies - 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 |
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Review of Systems
(ROS) - S |
5 to >3 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 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 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 |
|
Vital 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 |
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Labs, 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 |
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Medications-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 |
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Past 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 |
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Past Psychiatric
History-S |
4 to >3 pts Exemplary Includes (Outpatient and
Hospitalizations), for each psychiatric diagnosis (including addiction
treatment), and year of diagnosis. 3 to >2 pts Distinguished Includes (Outpatient and
Hospitalizations), for each psychiatric diagnosis (omits addiction treatment),
and year of diagnosis. 2 to >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 |
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Family Psychiatric
History-S |
4 to >3 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 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 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 |
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Social 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 |
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Mental Status Exam-O |
15 to >12 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 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 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 |
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Primary Diagnoses-A |
11 to >6 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 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 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 |
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Differential
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 |
|
Outcome 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 |
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Treatment |
10 to >8 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 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 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 |
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Patient/Family
Education-P |
5 to >3 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 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 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 |
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Referral |
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 |
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APA Formatting |
5 to >3 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 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 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 |
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References |
5 to >3 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 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 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 |
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