Comprehensive Psychotherapy Evaluation 3
Step 1: You will use the Graduate Comprehensive Psychotherapy Evaluation Template
Download Graduate Comprehensive Psychotherapy Evaluation Template
to:
1. Compose a written comprehensive psychotherapy evaluation of a patient you have seen in the clinic.
2. Upload your completed comprehensive psychotherapy evaluation as a Word doc. Scanned PDFs will not be accepted.
• For the Comprehensive Psychotherapy 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 Psychotherapy Evaluation Presentation 3 for more details.
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.
Subjective data: Patient’s Chief Complaint (CC); History of
S 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)
Objective data: Medications; Allergies; Past medical history;
O 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
Links to an external site.
or APA Clinical Guidelines
Links 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.
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.”
Graduate Mental Status Exam Guide
Download Graduate Mental Status Exam Guide
Successfully Capture HPI Elements in Psychiatry E/M Notes
Links to an external site.
AAPC Admin. (2013, August 1). Successfully capture HPI elements in psychiatry E/M notes. Advancing the Business of Healthcare. https://www.aapc.com/blog/25848successfully-capture-hpi-elements-in-psychiatry-em-notes/
Patient 12 – Schizophrenia, Paranoid Type
ICD-10: F20.0
Gender: Male
Insurance: Medicare Ethnicity: Caucasian
Chief Complaint: “People at work are spying and keep looking at me crazy.”
Race: White
Age: 46
Narrative (Procedures): PANSS elevated; MSE: anxious, persecutory delusions, auditory hallucinations, blunted affect. 3 Principal Diagnoses:
1. Schizophrenia, paranoid type – F20.0
2. Insomnia due to psychotic disorder – F51.05
3. Social Isolation – Z60.4
3 Differentials:
1. Delusional Disorder (F22): Hallucinations present → schizophrenia.
2. Schizoaffective Disorder (F25.1): No mood episodes.
3. MDD w/ Psychotic Features (F32.3): Psychosis independent of mood.
Pharmacological Treatment: Risperidone 2 mg PO BID × 30 days + Benztropine 0.5 mg PO BID PRN for EPS.
Education: Sedation possible; avoid alcohol; maintain regular follow-up.
RR/Ht/Wt/BMI: RR 18, Ht 5’10”, Wt 165 lb, BMI 23.7 (normal).
HPI: 46-year-old man with chronic paranoia and auditory hallucinations for 3 years. Recently stopped meds, symptoms worsened. Denies violence or SI. Maintains ADLs with mother’s supervision.
Sleep: 4 hours, frequent awakenings from fear.
