Please follow the attach instruction, and the Rubric, please make sure the psychotherapy note is well done, and the Mental Status Exam is well done
For this assignment, students will create a written comprehensive psychiatric evaluation of a patient they have seen in the clinic. Additionally, students will create a video presentation using a patient they have seen in the clinic. Each student will use the Graduate Psychotherapy Note Template to create a detailed psychiatric evaluation document. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. You will also create a focused SOAP note PowerPoint presentation. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
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 history; Past surgical 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; Follow up plan, diagnostic testing/screening tools, and follow up
Other: Incorporate current clinical guidelines ( (Links to an external site.)NIH Clinical Guidelines) (Links to an external site.) or APA Clinical Guidelines (Links to an external site.) research articles, and the role of the PMHNP in your presentation. Reminder: It is important that you complete this assessment using your critical thinking skills. You are expected to synthesis your clinical assessment, formulate a psychiatric diagnosis, and develop a treatment plan independently. It is not acceptable to document "my preceptor made this diagnosis."
Incorporate a minimum of four current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work. Journal articles and books should be referenced according to APA style, 7th Edition (the library has a copy of the APA Manual).
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