Comprehensive Psychiatric and/or Psychotherapy Evaluation 3
Step 1: You will use the Graduate Comprehensive Psychiatric/Psychotherapy Evaluation Template * to:
1. Compose a written comprehensive psychiatric and/or psychotherapy evaluation of a patient you have seen in the clinic.
2. Upload your completed comprehensive psychiatric and/or psychotherapy evaluation as a Word doc. Scanned PDFs will not be accepted.
• For the Comprehensive 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 Evaluation Presentation 3 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)
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 E or APA Clinical Guidelines G, research articles, and the role of the PMHNP in your evaluation.
• Psychiatric Assessment of Infants and Toddlers E›
• Psychiatric Assessment of Children and Adolescents G›
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
