Description Step 1: You will use the Graduate Comprehensive Psychiatric Evaluation Template Downloa ...
Description 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 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. 1 attachments Slide 1 of 1 attachment_1 attachment_1 UNFORMATTED ATTACHMENT PREVIEW Psychiatric SOAP Note Template Encounter date: ________________________ Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____ Reason for Seeking Health Care: ______________________________________________ HPI:_________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ SI/HI: _______________________________________________________________________________ Sleep: _________________________________________ Appetite: ________________________ Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________ Current perception of Health: Excellent Good Fair Poor Psychiatric History: Date Date Hospital Inpatient hospitalizations: Diagnoses Length of Stay Hospital Outpatient psychiatric treatment: Diagnoses Length of Stay Rev. 10162021 LM Date Hospital Detox/Inpatient substance treatment: Diagnoses Length of Stay History of suicide attempts and/or self injurious behaviors: ____________________________________ Past Medical History • Major/Chronic Illnesses____________________________________________________ • Trauma/Injury ___________________________________________________________ • Hospitalizations __________________________________________________________ Past Surgical History___________________________________________________________ Current psychotropic medications: _________________________________________ _________________________________________ _________________________________________ ________________________________ ________________________________ ________________________________ Current prescription medications: _________________________________________ _________________________________________ _________________________________________ ________________________________ ________________________________ ________________________________ OTC/Nutritionals/Herbal/Complementary therapy: _________________________________________ _________________________________________ ________________________________ ________________________________ Rev. 10162021 LM Substance use: (alcohol, marijuana, cocaine, caffeine, cigarettes) Substance Amount Frequency Length of Use Family Psychiatric History: _____________________________________________________ Social History Lives: Single family House/Condo/ with stairs: ___________ Marital Status:________ Education:____________________________ Employment Status: ______ Current/Previous occupation type: _________________ Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________ Sexual Orientation: _______ Sexual Activity: ____ Contraception Use: ____________ Family Composition: Family/Mother/Father/Alone: _____________________________ Rev. 10162021 LM Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________ ________________________________________________________________________ Health Maintenance Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____ Exposures: Immunization HX: Review of Systems: General: HEENT: Neck: Lungs: Cardiovascular: Breast: GI: Male/female genital: GU: Neuro: Musculoskeletal: Activity & Exercise: Rev. 10162021 LM Psychosocial: Derm: Nutrition: Sleep/Rest: LMP: STI Hx: Physical Exam BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (percentile) _____ General: HEENT: Neck: Pulmonary: Cardiovascular: Breast: GI: Male/female genital: GU: Neuro: Rev. 10162021 LM Musculoskeletal: Derm: Psychosocial: Misc. Mental Status Exam Appearance: Behavior: Speech: Mood: Affect: Thought Content: Thought Process: Cognition/Intelligence: Clinical Insight: Clinical Judgment: Rev. 10162021 LM Significant Data/Contributing Dx/Labs/Misc. Plan: Differential Diagnoses 1. 2. Principal Diagnoses 1. 2. Plan Diagnosis #1 Diagnostic Testing/Screening: Pharmacological Treatment: Non-Pharmacological Treatment: Education: Referrals: Follow-up: Rev. 10162021 LM Anticipatory Guidance: Diagnosis #2 Diagnostic Testingg/Screenin: Pharmacological Treatment: Non-Pharmacological Treatment: Education: Referrals: Follow-up: Anticipatory Guidance: Signature (with appropriate credentials): __________________________________________ Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________ Rev. 10162021 LM DEA#: 101010101 STU Clinic LIC# 10000000 Tel: (000) 555-1234 FAX: (000) 555-12222 Patient Name: (Initials)______________________________ Age ___________ Date: _______________ RX ______________________________________ SIG: Dispense: ___________ Refill: _________________ No Substitution Signature: ____________________________________________________________ Rev. 10162021 LM Purchase answer to see full attachment Explanation & Answer: 1 Worksheet User generated content is uploaded by users for the purposes of learning and should be used following Studypool's honor code & terms of service.
