please see all attachments as this assignment will be for an initial psych evaluation and should be on a patient with multiple medical conditions and the prescribed medication should not be a med patient is already taking.
Comprehensive Psychiatric Evaluation Template
With Psychotherapy Note
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:
Inpatient hospitalizations:
|
Date |
Hospital |
Diagnoses |
Length of Stay |
Outpatient psychiatric treatment:
|
Date |
Hospital |
Diagnoses |
Length of Stay |
Detox/Inpatient substance treatment:
|
Date |
Hospital |
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:
_________________________________________ ________________________________
_________________________________________ ________________________________
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 : _____________________________
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________
________________________________________________________________________
Health Maintenance
Screening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, Dementia
Exposures:
Immunization HX:
Review of Systems (at least 3 areas per system):
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
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:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
Mental Status Exam
Appearance:
Behavior:
Speech:
Mood:
Affect:
Thought Content:
Thought Process:
Cognition/Intelligence:
Clinical Insight:
Clinical Judgment:
|
Psychotherapy Note |
|
Therapeutic Technique Used: |
|
Session Focus and Theme: |
|
Intervention Strategies Implemented: |
|
Evidence of Patient Response: |
Plan:
Differential Diagnoses
1.
2.
Principal Diagnoses
1.
2.
Plan:
Diagnosis #1
Diagnostic Testing/Screening:
Pharmacological Treatment:
Non-Pharmacological Treatment:
Patient/Family Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Diagnosis #2
Diagnostic Testing/Screening Tool:
Pharmacological Treatment:
Non-Pharmacological Treatment:
Patient/Family Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Signature (with appropriate credentials): __________________________________________
Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________
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. 2272022 LM
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Psychiatric/Psychotherapy SOAP Note Rubric
|
Criteria |
Ratings |
Points |
|||
|
Chief Complaint (Reason for seeking health care) – S |
4 to >3.0 points Exemplary Includes a direct quote from patient about presenting problem. |
3 to >2.0 points Distinguished Includes a direct quote from patient and other unrelated information. |
2 to >0.0 points Developing Includes information but information is NOT a direct quote. |
0 points Novice Information is completely missing. |
4 points |
|
Demographics – S |
2 points Exemplary Begins with patient initials, age, race, ethnicity, and gender (5 demographics). |
1.5 points Distinguished Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity, and gender). |
1 points Developing Begins with 3 or less patient demographics (patient initials, age, race, ethnicity, and gender). |
0 points Novice Information is completely missing. |
2 points |
|
History of the Present Illness (HPI) – S |
5 to >3.0 points Exemplary Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity). |
3 to >2.0 points Distinguished Includes the presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity). |
2 to >1.0 points Developing Includes the presenting problem and 4 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity). |
1 to >0 points Novice The presenting problem is not clearly stated and/or there are < 4 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity). |
5 points |
|
Allergies – S |
2 points Exemplary Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy). |
1.5 points Distinguished If allergies are present, student does not list each type of drug, environmental factor, herbal, food, latex name and include severity of allergy OR description of the allergy. |
1 points Developing If allergies are present, student only lists the type of allergy and omits the name of the allergy. |
0 points Novice Information is completely missing. |
2 points |
|
Review of Systems (ROS) – S |
5 to >3.0 points Exemplary Includes a minimum of 3 assessments for each body system, assesses at least 9 body systems directed to chief complaint, AND uses the words “admits” and “denies.” |
3 to >2.0 points Distinguished Includes 3 or fewer assessments for each body system, assesses 5-8 body systems directed to chief complaint, AND uses the words “admits” and “denies.” |
2 to >0.0 points Developing Includes 3 or fewer assessments for each body system, and assesses less than 5 body systems directed to chief complaint, OR student does not use the words “admits” and “denies.” |
0 points Novice Information is completely missing. |
5 points |
|
Vital Signs – O |
2 points Exemplary Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain). |
1.5 points Distinguished Includes at least 6 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain). |
1 points Developing Includes at least 4 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain). |
0 points Novice Information is completely missing. |
2 points |
|
Labs, Diagnostic Tests and Screening Tools – O |
3 points |
