You will complete a comprehensive psychiatric mental health assessment of a child/adolescent. This should NOT be a patient you have encountered in your work but, instead, should be a family member

Jamez

10 Nov 2024 • 10 min read

You will complete a comprehensive psychiatric mental health assessment of a child/adolescent. This should NOT be a patient you have encountered in your work but, instead, should be a family member or friend (who gives consent). You should note that all information will be confidential and that their private information will NOT be shared as part of this assignment. Your assessment should be comprehensive, and you should refer to course texts to inform items for inclusion in your assessment. Keep in mind that you will be responsible for covering those areas addressed in the reading assignments up to this point. The documentation should remain HIPAA-compliant even though this is not a real patient. (DO NOT USE REAL PATIENT IDENTIFIERS.) Be sure to include birth and developmental information as well as school and behavior information for the child. Consider cultural, gender, ethnicity, spiritual, and social competencies needed to formulate the best care plan for the patient.

The patient will be referred to as Jane Doe or Jack Doe.

Use the Initial Psychiatric Assessment SOAP Note Template to complete this assignmen

Grading Rubric

Assignment Criteria	Level III	Level II	Level I	Not Present
Criteria 1	Level III Max Points Points: 8	Level II Max Points Points: 6.4	Level I Max Points Points: 4.8	0 Points
Subjective Information	● Complete and concise summary of pertinent information.	● Well organized; partial but accurate summary of pertinent information (>80%).	● Poorly organized and/or limited summary of pertinent information (50%-80%); information other than “S” provided.	● Does not meet the criteria
Assignment Criteria	Level III	Level II	Level I	Not Present
Criteria 2	Level III Max Points Points: 8	Level II Max Points Points: 6.4	Level I Max Points Points: 4.8	0 Points
Objective Information	● Complete and concise summary of pertinent information.	● Partial but accurate summary of pertinent information (>80%).	● Poorly organized and/or limited summary of pertinent information (50%-80%); information other than “O” provided.	● Does not meet the criteria
Assignment Criteria	Level III	Level II	Level I	Not Present
Criteria 3	Level III Max Points Points: 8	Level II Max Points Points: 6.4	Level I Max Points Points: 4.8	0 Points
Assessment: Problem Identification and Prioritization	● Complete problem list generated and rationally prioritized; no extraneous information or issues listed.	● Most problems are identified and rationally prioritized, including the “main” problem for the case (>80%).	● Some problems are identified (50%-80%); incomplete or inappropriate problem prioritization; includes nonexistent problems or extraneous information included.	● Does not meet the criteria
Criteria 4	Level III Max Points Points: 8	Level II Max Points Points: 6.4	Level I Max Points Points: 4.8	0 Points
Assessment: Assessment of Current Psychiatric & Medical Condition(s) or Drug Therapy-related Problem	● An optimal and thorough assessment is present for each problem	● An assessment is present for each problem listed but not optimal	● Assessment is present for 50-80% of problems	● Does not meet the criteria
Assignment Criteria	Level III	Level II	Level I	Not Present
Criteria 5	Level III Max Points Points: 6	Level II Max Points Points: 4.8	Level I Max Points Points: 3.6	0 Points
Assessment: Treatment Goals	● Appropriate and relevant therapeutic goals for each identified problem.	● Appropriate therapeutic goals for most identified problems (>80%).	● Appropriate therapeutic goals for a few identified problems (50%-80%).	● Less than 50% of problems have appropriate therapeutic goals.
Assignment Criteria	Level III	Level II	Level I	Not Present
Criteria 6	Level III Max Points Points: 6	Level II Max Points Points: 4.8	Level I Max Points Points: 3.6	0 Points
Plan: Treatment Plan	● Specific, appropriate and justified recommendations (including drug name, strength, route, frequency, and duration of therapy) for each identified problem are included.	● Includes most of the requirements for each identified problem (>80%).	● Incomplete and/or inappropriate for a few identified problems (50%-80%); information other than “P” provided.	● Less than 50% of problems have an appropriate and complete treatment plan.
Criteria 7	Level III Max Points Points: 6	Level II Max Points Points: 4.8	Level I Max Points Points: 3.6	0 Points
Plan: Counseling, Referral, Monitoring & Follow-up	● Specific patient education points, monitoring parameters, follow-up plan and (where applicable) referral plan for each identified problem.	● Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for >80% of identified problems.	● Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for a few identified problems (50%-80%).	● Less than 50% of problems include appropriate counseling, monitoring, referral and/or follow-up plan.
Maximum Total Points	50	40	30
Minimum Total Points	41 points minimum	31 points minimum	1 point minimum

Initial Psychiatric SOAP Note Template

There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to develop your style of SOAP in the psychiatric practice setting.

Criteria	Clinical Notes

Informed Consent	Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion)
Subjective	Verify Patient Name: DOB: Minor: Accompanied by: Demographic: Gender Identifier Note: CC: HPI: Pertinent history in record and from patient: X During assessment: Patient describes their mood as X and indicated it has gotten worse in TIME. Patient self-esteem appears fair, no reported feelings of excessive guilt, no reported anhedonia, does not report sleep disturbance, does not report change in appetite, does not report libido disturbances, does not report change in energy, no reported changes in concentration or memory. Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. Patient does not report excessive fears, worries or panic attacks. Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a characterological nature. SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors. Allergies: NKDFA. (medication & food) Past Medical Hx: Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury. Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C. Surgical history no surgical history reported If Minor obtain Developmental Hx: (most often from parents), in utero, birth and delivery hx, early childhood, school hx, behavior, etc… Nutritional status (this is an important component to gauge how well the mind and body are being nourished for full function. Ex: lack of iodine create thyroid issues, thyroid issues creates metabolism issues which affects function of cognition, mood, etc…) Past Psychiatric Hx: Previous psychiatric diagnoses: none reported. Describes stable course of illness. Previous medication trials: none reported. Safety concerns: History of Violence to Self: none reported History of Violence to Others: none reported Auditory Hallucinations: Visual Hallucinations: Mental health treatment history discussed: History of outpatient treatment: not reported Previous psychiatric hospitalizations: not reported Prior substance abuse treatment: not reported Trauma history: Client does not report history of trauma including abuse, domestic violence, witnessing disturbing events. Substance Use: Client denies use or dependence on nicotine/tobacco products. Client does not report abuse of or dependence on ETOH, and other illicit drugs. Current Medications: No current medications. (Contraceptives): Supplements: Past Psych Med Trials: Family Medical Hx: Family Psychiatric Hx: Substance use Suicides Psychiatric diagnoses/hospitalization Developmental diagnoses Social History: Occupational History: currently unemployed. Denies previous occupational hx Military service History: Denies previous military hx. Education history: completed HS and vocational certificate Developmental History: no significant details reported. (Childhood History) Legal History: no reported/known legal issues, no reported/known conservator or guardian. Spiritual/Cultural Considerations: none reported. ROS: Constitutional: No report of fever or weight loss. Eyes: No report of acute vision changes or eye pain. ENT: No report of hearing changes or difficulty swallowing. Cardiac: No report of chest pain, edema or orthopnea. Respiratory: Denies dyspnea, cough or wheeze. GI: No report of abdominal pain. GU: No report of dysuria or hematuria. Musculoskeletal: No report of joint pain or swelling. Skin: No report of rash, lesion, abrasions. Neurologic: No report of seizures, blackout, numbness or focal weakness. Endocrine: No report of polyuria or polydipsia. Hematologic: No report of blood clots or easy bleeding. Allergy: No report of hives or allergic reaction. Reproductive: No report of significant issues. (females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…)
Verify Patient: Name, Assigned identification number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo. Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview. HPI: , Past Medical and Psychiatric History, Current Medications, Previous Psych Med trials, Allergies. Social History, Family History. Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…”
Objective	Vital Signs: Stable Temp: BP: HR: R: O2: Pain: Ht: Wt: BMI: BMI Range: LABS: Lab findings WNL Tox screen: Negative Alcohol: Negative HCG: N/A Physical Exam: MSE: Patient is cooperative and conversant, appears without acute distress, and fully oriented x 4. Patient is dressed appropriately for age and season. Psychomotor activity appears within normal. Presents with appropriate eye contact, euthymic affect - full, even, congruent with reported mood of “x”. Speech: spontaneous, normal rate, appropriate volume/tone with no problems expressing self. TC: no abnormal content elicited, denies suicidal ideation and denies homicidal ideation. Process appears linear, coherent, goal-directed. Cognition appears grossly intact with appropriate attention span & concentration and average fund of knowledge. Judgment appears fair . Insight appears fair The patient is able to articulate needs, is motivated for compliance and adherence to medication regimen. Patient is willing and able to participate with treatment, disposition, and discharge planning. Diagnostic testing: · PHQ-9, psychiatric assessment
This is where the “facts” are located. Vitals, *Physical Exam (if performed, will not be performed every visit in every setting) Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results.*
Assessment	DSM5 Diagnosis: with ICD-10 codes Dx: - Dx: - Dx: - Patient has the ability/capacity appears to respond to psychiatric medications/psychotherapy and appears to understand the need for medications/psychotherapy and is willing to maintain adherent. Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment.
Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment. Informed Consent Ability
Plan	Inpatient: Psychiatric. Admits to X as per HPI. Estimated stay 3-5 days Patient is found to be stable and has control of behavior. Patient likely poses a minimal risk to self and a minimal risk to others at this time. Patient denies abnormal perceptions and does not appear to be responding to internal stimuli. Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic: · No changes to current medication, as listed in chart, at this time · or…Zoloft is an excellent option for many women who experience any menstrual cycle complaints. I usually start at 50 mg and move to 100 week 6-8. f/u within 2 weeks initially then every 6-8 weeks. Psychotherapy referral for CBT Education, including health promotion, maintenance, and psychosocial needs Importance of medication Discussed current tobacco use. NRT not indicated. Safety planning Discuss worsening sx and when to contact office or report to ED Referrals: endocrinologist for diabetes Follow-up, including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit 2 weeks ☒ > 50% time spent counseling/coordination of care. Time spent in Psychotherapy 18 minutes Visit lasted 55 minutes Billing Codes for visit: XX XX XX ____________________________________________ NAME, TITLE Date: Click here to enter a date. Time: X
Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options and complimentary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment and include patient education.

Initial Psychiatric SOAP Note Template

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