Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.

Comprehensive Psychiatric Evaluation 1
Step 1: You will use the Graduate Comprehensive Psychiatric Evaluation Template Download Graduate Comprehensive Psychiatric Evaluation Templateto:
Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.
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.
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
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.”
Submission Instructions:
Upload your completed Comprehensive Psychiatric Evaluation as a word document. It will be assessed through Turnitin.
Psychiatric SOAP Note Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeChief Complaint (Reason for seeking health care) – S
4 to >3.0 ptsExemplaryIncludes a direct quote from patient about presenting problem. 3 to >2.0 ptsDistinguishedIncludes a direct quote from patient and other unrelated information. 2 to >0.0 ptsDevelopingIncludes information but information is NOT a direct quote. 0 ptsNoviceInformation is completely missing.
4 pts
This criterion is linked to a Learning OutcomeDemographics – S
2 ptsExemplaryBegins with patient initials, age, race, ethnicity, and gender (5 demographics). 1.5 ptsDistinguishedBegins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity, and gender). 1 ptsDevelopingBegins with 3 or less patient demographics (patient initials, age, race, ethnicity, and gender). 0 ptsNoviceInformation is completely missing.
2 pts
This criterion is linked to a Learning OutcomeHistory of the Present Illness (HPI) – S
5 to >3.0 ptsExemplaryIncludes 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 >2.0 ptsDistinguishedIncludes 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 >1.0 ptsDevelopingIncludes 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 ptsNoviceThe 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 This criterion is linked to a Learning OutcomeAllergies – S 2 ptsExemplaryIncludes 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 ptsDistinguishedIf 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 ptsDevelopingIf allergies are present, student only lists the type of allergy and omits the name of the allergy. 0 ptsNoviceInformation is completely missing. 2 pts This criterion is linked to a Learning OutcomeReview of Systems (ROS) – S 5 to >3.0 ptsExemplaryIncludes 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 >2.0 ptsDistinguishedIncludes 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 >0.0 ptsDevelopingIncludes 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 ptsNoviceInformation is completely missing.
5 pts
This criterion is linked to a Learning OutcomeVital Signs – O
2 ptsExemplaryIncludes 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 ptsDistinguishedIncludes 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 ptsDevelopingIncludes 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 ptsNoviceInformation is completely missing.
2 pts
This criterion is linked to a Learning OutcomeLabs, Diagnostic Tests and Screening Tools – O
3 ptsExemplaryDuring 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 ptsDistinguishedDuring 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 ptsDevelopingDuring 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 ptsNoviceInformation is completely missing.
3 pts
This criterion is linked to a Learning OutcomeMedications-S
3 ptsExemplaryIncludes a list of all of the patient reported psychiatric and medical medications and the diagnosis for the medication (including name, dose, route, frequency). 2 ptsDistinguishedIncludes 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 ptsDevelopingIncludes 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 ptsNoviceInformation is completely missing.
3 pts
This criterion is linked to a Learning OutcomePast Medical History-S
3 ptsExemplaryIncludes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current. 2 ptsDistinguishedIncludes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current. 1 ptsDevelopingIncludes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current. 0 ptsNoviceInformation is completely missing.
3 pts
This criterion is linked to a Learning OutcomePast Psychiatric History-S
4 to >3.0 ptsExemplaryIncludes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), and year of diagnosis. 3 to >2.0 ptsDistinguishedIncludes (Outpatient and Hospitalizations), for each psychiatric diagnosis (omits addiction treatment), and year of diagnosis. 2 to >0.0 ptsDevelopingIncludes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), and does not include the year of diagnosis. 0 ptsNoviceThe information is completely missing.
4 pts
This criterion is linked to a Learning OutcomeFamily Psychiatric History-S
4 to >3.0 ptsExemplaryIncludes 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 >2.0 ptsDistinguishedIncludes 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 >0.0 ptsDevelopingIncludes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder, and history of suicidal attempts. 0 ptsNoviceInformation is completely missing.
4 pts
This criterion is linked to a Learning OutcomeSocial History-S
3 ptsExemplaryDistinguished 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 ptsDistinguishedIncludes 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 ptsDevelopingIncludes 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
This criterion is linked to a Learning OutcomeMental Status Exam-O
15 to >12.0 ptsExemplaryIncludes 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 >10.0 ptsDistinguishedIncludes 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 >0.0 ptsDevelopingIncludes >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 ptsNoviceIncludes <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 This criterion is linked to a Learning OutcomePrimary Diagnoses-A 11 to >6.0 ptsExemplaryIncludes 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 >3.0 ptsDistinguishedIncludes 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 >0.0 ptsDevelopingIncludes an inaccurate diagnosis as the principal diagnosis. The ICD-10 code is incorrect or missing. 0 ptsNoviceInformation is completely missing.
11 pts
This criterion is linked to a Learning OutcomeDifferential Diagnoses-A
3 ptsExemplaryIncludes 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 ptsDistinguishedIncludes 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 ptsDevelopingIncludes at least 1 differential diagnosis that is NOT supported by the subjective and objective data. The ICD-10 code is incorrect or missing. 0 ptsNoviceInformation is completely missing.
3 pts
This criterion is linked to a Learning OutcomeOutcome Labs/Screening Tools – O
3 ptsExemplaryAfter 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 ptsDistinguishedAfter 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 ptsDevelopingAfter the visit, orders appropriate diagnostic testing less than 50% of the time. 0 ptsNoviceInformation is completely missing.
3 pts
This criterion is linked to a Learning OutcomeTreatment
10 to >8.0 ptsExemplaryIncludes 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 >6.0 ptsDistinguishedIncludes 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 >0.0 ptsDevelopingIncludes 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 ptsNoviceInformation is completely missing.
10 pts
This criterion is linked to a Learning OutcomePatient/Family Education-P
5 to >3.0 ptsExemplaryIncludes 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 >2.0 ptsDistinguishedIncludes 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 >0.0 ptsDevelopingIncludes 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 ptsNoviceInformation is completely missing.
5 pts
This criterion is linked to a Learning OutcomeReferral
3 ptsExemplaryProvides 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 ptsDistinguishedProvides a medical or other interdisciplinary referral or documents NO REFERRAL ADVISED AT THIS TIME. Includes a timeline for follow up appointments. 1 ptsDevelopingProvides a medical or other interdisciplinary referral. DOES NOT include a timeline for follow up appointments. 0 ptsNoviceInformation is completely missing.

 

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