Step 1: You will use the: Graduate Comprehensive Psychiatric Evaluation Template

Step 1: You will use the: Graduate Comprehensive Psychiatric Evaluation Template
Compose a written comprehensive psychiatric evaluation of a patient you have seen in the Psychiatric clinic.
Step 2: Each student will create a focused SOAP note PowerPoint presentation. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive psychiatric 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 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 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.” An example of the appropriate descriptors of the clinical evaluation is listed below. It is not acceptable to document “within normal limits.”
Graduate Mental Status Exam Guide
Successfully Capture HPI Elements in Psychiatry E/M Notes
AAPC Admin. (2013, August 1). Successfully capture HPI elements in psychiatry E/M notes. Advancing the Business of Healthcare. https://www.aapc.com/blog/25848-successfully-captu…
Submission Instructions:
The presentation is original work and logically organized, formatted, and cited in the current APA style, including citation of references.
Upload your completed Comprehensive Psychiatric Evaluation as word document
Then, have your preceptor sign and date your completed Comprehensive Psychiatric Evaluation, on the comprehensive psychiatric evaluation document to confirm they have reviewed and acknowledge this patient was seen in their clinic.
No typed signatures will be accepted. Secure your preceptor’s signature in time for your presentation.
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).