Comprehensive Psychiatric Evaluation 1

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

Download Graduate Comprehensive Psychiatric Evaluation Template

1. Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.
   • Your preceptor MUST sign their initials on the comprehensive psychiatric evaluation document to confirm they have reviewed and acknowledge this patient was seen in their clinic.
2. You will then use Canvas Studio Screen Capture and Webcam (I want to see your face and your document at the same time) to record yourself presenting your completed comprehensive psychiatric evaluation document.
   • Use ONLY Canvas Studio to record your comprehensive psychiatric evaluation and verbal presentation. No other medium will be accepted.
   • How do I record a Canvas Studio video with a webcam in a course? 

• Links to an external site.

 

• How do I create a video with a PowerPoint in Canvas Studio Screen Capture 

1.  
   • Links to an external site.

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

Links to an external site.

 or 

APA Clinical Guidelines

Links to an external site., research articles, and the role of the PMHNP in your presentation.  

• Psychiatric Assessment of Infants and Toddlers 
• Links to an external site.

 

• Psychiatric Assessment of Children and Adolescents 
• Links to an external site.

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

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/25848-successfully-capture-hpi-elements-in-psychiatry-em-notes/

 

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).
• You will use this signed template for your video presentation. The signature should be visible by faculty during your presentation (you should also state this is my preceptor’s signature) during your presentation.
• The presentation should be less than 7 minutes in length.
• You must show your identification at the beginning of the presentation, or the presentation will not be graded.
• You must wear your lab coat and conduct the video in a professional setting, or the presentation will not be graded.
• You must submit upload your document to Canvas
• You will submit the link to your video presentation as a comment in the assignment portion of the course
• Complete and submit the assignment by 11:59 PM ET Sunday.

 

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