For this assignment, students will create a written comprehensive psychiatric evaluation of a patient they have seen in the clinic. Your preceptor must sign their initials on this document to confirm they have reviewed and acknowledge this patient was seen in their clinic. Each student will use the Graduate Psychotherapy Note Template Download Graduate Psychotherapy Note Template to create a detailed psychiatric evaluation document. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive psychiatric evaluation 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) (Links to an external site.) (Links to an external site.) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS); Review of Systems (ROS).
O Objective data: Medications; Allergies; Past medical history; Family 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 Nonpharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up.
The paper is to be clear and concise, and students will lose points for improper grammar, punctuation and misspelling.
The paper should be formatted per current APA and 8-10 pages in length, excluding the title, abstract and references page. Incorporate a minimum of 5 current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work.
Please use attach Template
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