Comprehensive Psychiatric Assessment and SOAP Note for Adolescent Patient: Incorporating Current Research and Clinical Guidelines
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ASSIGNMENT INSTRUCTIONS:
Step 1: You will use the: Graduate Comprehensive Psychiatric Evaluation Template
Compose a written comprehensive psychiatric evaluation of an adolescent psychiatric patient you have seen in the 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 will 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.
Psychiatric Assessment of Infants and Toddlers
Psychiatric Assessment of Children and Adolescents
Reminder: You must 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 unacceptable to document that “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:
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).
Grading Rubric
Your assignment will be graded according to the grading rubric.
View Rubric
NUR 630CL Video Case Presentation and Psychiatric SOAP Note Rubric 2022
NUR 630CL Video Case Presentation and Psychiatric SOAP Note Rubric 2022
CriteriaRatingsPts
Chief Complaintview longer description
4 to >3 pts
Exemplary
Includes a direct quote from the patient about presenting the problem3 to >2 pts
Distinguished
Includes a direct quote from the patient and other unrelated information2 to >0 pts
Developing
Includes information but the information is NOT a direct quote0 pts
Novice
Information is completely missing/ 4 pts
Demographics – S
view longer description
2 pts
Exemplary
Begins with patient initials, age, race, ethnicity, and gender (5 demographics)1.5 pts
Distinguished
Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity, and gender)1 pts
Developing
Begins with 3 or fewer patient demographics (patient initials, age, race, ethnicity, and gender)0 pts
Novice
Information is completely missing/ 2 pts
History of the Present Illness (HPI) – S
view longer description
5 to >3 pts
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 pts
Distinguished
Includes the presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing2 to >1 pts
Developing
Includes the presenting problem and 4 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing1 to >0 pts
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/ 5 pts Allergies – S view longer description 2 pts 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 pts Distinguished If allergies are present, student does not list each type of drug, environmental factor, herbal, food, latex name and include the severity of allergy OR description of th, the student only lists the type of allergy and omits the name of the allergy0 pts Novice Information is completely missing/ 2 pts Review of Systems (ROS) – S view longer description 5 to >3 pts
Exemplary
Includes a minimum of 3 assessments for each body system, assesses at least 9 body systems directed to the chief complaint, AND uses the words “admits” and “denies”3 to >2 pts
Distinguished
Includes 3 or fewer assessments for each body system, assesses 5-8 body systems directed to the chief complaint, AND uses the words “admits” and “denies”2 to >0 pts
Developing
Includes 3 or fewer assessments for each body system, and assesses less than 5 body systems directed to the chief complaint, OR student does not use the words “admits” and “denies”0 pts
Novice
Information is completely missing/ 5 pts
Vital Signs – O
view longer description
2 pts
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 pts
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 pts
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 pts
Novice
Information is completely missing/ 2 pts
Labs, Diagnostic Tests, and Screening Tools – O
view longer description
3 pts
Exemplary
During the visit: Includes a list of the labs, diagnostic tests, or screening tools reviewed at the visit, values of lab results or screening tools, and highlights abnormal values, OR acknowledges no labs/diagnostic tests were reviewed.2 pts
Distinguished
During the visit: Includes a list of the labs, diagnostic tests, or screening tools reviewed at the visit, but does not include the values of lab results or screening tools, but does not highlight abnormal values.1 pts
Developing
During the visit: Includes a list of the labs, diagnostic tests, or screening tools reviewed at the visit but does not include the values of the results or highlight abnormal values.0 pts
Novice
Information is completely missing./ 3 pts
Medications-S
view longer description
3 pts
Exemplary
Includes a list of all of the patient-reported psychiatric and medical medications and the diagnosis for the medication (including name, dose, route, frequency)2 pts
Distinguished
Includes a list of all of the patient-reported psychiatric and but omits the medical medications and the diagnosis for the medication (including name, dose, route, frequency)1 pts
Developing
Includes a list of some of the patient-reported psychiatric and/or medical medications and the diagnosis for the medication (omits the dose, route, and frequency of the medications)0 pts
Novice
Information is completely missing/ 3 pts
Past Medical History-S
view longer description
3 pts
Exemplary
Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis, and whether the diagnosis is active or current2 pts
Distinguished
Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current1 pts
Developing
Includes each medical diagnosis but does not include the year of diagnosis or whether the diagnosis is active or current0 pts
Novice
Information is completely missing/ 3 pts
Past Psychiatric History-S
view longer description
3 pts
Exemplary
Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), year of diagnosis and2 pts
Distinguished
Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (omits addiction treatment), year of diagnosis1 pts
Developing
Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), does not include the year of diagnosis0 pts
Novice
The information is completely missing/ 3 pts
Family Psychiatric History-S
view longer description
3 pts
Exemplary
Includes an assessment of at least 6 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder, and history of suicidal attempts2 pts
Distinguished
Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder, and history of suicidal attempts1 pts
Developing
Includes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder, and history of suicidal attempts0 pts
Novice
Information is completely missing/ 3 pts
Social History-S
view longer description
3 pts
Exemplary
Distinguished Includes all 11 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation.2 pts
Distinguished
Includes at least 8 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation.1 pts
Developing
Includes all 6 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation.0 pts
Novice
Information is completely missing./ 3 pts
Mental Status Exam-O
view longer description
15 to >10 pts
Exemplary
Includes all 10 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight, and judgment) with detailed descriptions for each area10 to >5 pts
Distinguished
Includes all 8 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight, and judgment) with detailed descriptions for each area5 to >0 pts
Developing
Includes >6 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight, and judgment) with some descriptions for each area0 pts
Novice
Includes <3 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight, and judgment) OR detailed descriptions are not included for each area/ 15 pts Primary Diagnoses-A view longer description 8 to >4 pts
Exemplary
Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)4 to >2 pts
Distinguished
Includes a clear outline of the accurate diagnoses addressed at the visit but does not list the diagnoses in descending order of priority2 to >0 pts
Developing
Includes an inaccurate diagnosis as the principal diagnosis0 of pts
Novice
Information is completely missing/ 8 pts
Differential Diagnoses-A
view longer description
3 pts
Exemplary
Includes at least 2 differential diagnoses that can be supported by the subjective and objective data provided.2 pts
Distinguished
Includes 1 differential diagnosis that can be supported by the subjective and objective data provided.1 pts
Developing
Includes at least 1 differential diagnosis that is NOT supported by the subjective and objective data0 pts
Novice
Information is completely missing/ 3 pts
Outcome Labs/Screening Tools – O
view longer description
3 pts
Exemplary
After the visit: orders appropriate diagnostic/lab testing or screening tool 100% of the time OR acknowledges “no diagnostic testing or screening tool clinically required at this time”2 pts
Distinguished
After the visit: orders appropriate diagnostic/lab testing 50% of the time OR acknowledges “no diagnostic testing or screening tool clinically required at this time”1 pts
Developing
After the visit, orders for appropriate diagnostic testing are less than 50% of the time.0 pts
Novice
Information is completely missing./ 3 pts
Treatment
view longer description
10 to >7.5 pts
Exemplary
Includes a detailed pharmacologic and nonpharmacological treatment plan for each diagnosis listed under “assessment”. The plan includes ALL of the following: drug/vitamin/herbal name, dose, route, frequency, duration, and cost as well as education related to pharmacologic agents. For non-pharmacological treatment, includes treatment name, frequency, and duration. If the diagnosis is a chronic problem, the student includes instructions on currently prescribed medications as above. The plan is supported by the current US clinical guidelines. of 7.5 to >3.5 pts
Distinguished
Includes a detailed pharmacologic and nonpharmacological treatment plan for each diagnosis listed under “assessment”. The plan includes 4-7 of the following: drug/vitamin/herbal name, dose, route, frequency, duration, and cost as well as education related to pharmacologic agents. For non-pharmacological treatment, includes treatment name, frequency, and duration. If the diagnosis is a chronic problem, the student includes instructions on currently prescribed medications as above. The plan is supported by the current US clinical guidelines. of 3.5 to >0 pts
Developing
Includes a detailed pharmacologic and nonpharmacological treatment plan for each diagnosis listed under “assessment”. The plan includes 4 of the following: drug/vitamin/herbal name, dose, route, frequency, duration and cost as well as education related to the pharmacologic agent. Non-pharmacological treatment NOT included. If the diagnosis is a chronic problem, the student includes instructions on currently prescribed medications as above. The plan is NOT supported by the current US clinical guidelines OR is unsafe.0 pts
Novice
Information is completely missing/ 10 pts
Patient/Family Education-P
view longer description
5 to >3 pts
Exemplary
Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives.3 to >2 pts
Distinguished
Includes at least 2 strategies to promote and develop skills for managing their illness and at least 2 self-management methods on how to incorporate healthy behaviors into their lives.2 to >0 pts
Developing
Includes at least 1 strategy to promote and develop skills for managing their illness and at least 1 self-management method on how to incorporate healthy behaviors into their lives.0 pts
Novice
Information is completely missing./ 5 pts
Referral
view longer description
3 pts
Exemplary
Provides a detailed list of medical and other interdisciplinary referrals or documents NO REFERRAL ADVISED AT THIS TIME. Includes a timeline for follow-up appointments.2 pts
Distinguished
Provides a medical or other interdisciplinary referral or documents NO REFERRAL ADVISED AT THIS TIME. Includes a timeline for follow-up appointments.1 pts
Developing
Provides a medical or other interdisciplinary referral. DOES NOT include a timeline for follow-up appointments.0 pts
Novice
Information is completely missing./ 3 pts
APA Formatting
view longer description
5 to >3 pts
Exemplary
Effectively uses literature and other resources to inform their work. Exceptional use of citations and extended referencing. High level of precision with APA 7th Edition writing style.3 to >2 pts
Distinguished
Effectively uses literature and other resources to inform their work. The moderate use of citations and extended referencing. Moderate level of precision with APA 7th Edition writing style.2 to >0 pts
Developing
Ineffectively uses literature and other resources to inform their work. The moderate use of citations and extended referencing. APA 7th Edition writing style not strictly adhered to.0 pts
Novice
APA style and writing mechanics not used./ 5 pts
Audio-Video Presentation
view longer description
5 to >3.5 pts
Exemplary
The audio-Video presentation contains the signed copy of the psychiatric soap note with references. Well-rehearsed. Voice, eye contact, and pacing hold the interest and attention of the audience; introduced self and clinical case.3.5 to >1.5 pts
Distinguished
The audio-Video presentation contains the clinical psychiatric note but it was not signed or the references were missing. Fairly fluid delivery. Communicates ideas with proper voice projection; perhaps one mispronounced work; made eye contact1.5 to >0 pts
Developing
The audio-Video presentation contains a signed psychiatric note but does not include the references. The presentation does not accurately portray the therapeutic intervention or content of the presentation. Some difficulty communicating ideas. Poor voice projections; some eye contact; no introduction; mispronounced a few words; long pauses; somewhat confused.0 pts
Novice
The audio-Video presentation was not submitted or the video was not created using the audio or video platform required in the instructions. Great difficulty communicating ideas. Poor voice projection; no eye contact; no introduction; mispronounced words; stopped or had long pauses; read from notes/ 5 pts
References
view longer description
5 to >3.33 pts
Exemplary
2 pts Distinguished The reference page contains at least the required current scholarly academic reference and text reference. Follows APA guidelines of components: double space, 12 pt. font, abstract, level headings, hanging indent, and in-text citations.3.33 to >1.67 pts
Distinguished
The references page contains one current scholarly academic resource and text reference. Follows most APA guidelines of components: double space, 12 pt. font, abstract, level headings, hanging indent, and in-text citations1.67 to >0 pts
Developing
The references page contains one current or outdated scholarly academic resource. Many errors of APA guidelines: double space, 12 pt. font, abstract, level headings, hanging indent, and in-text citations.0 pts
Novice
The references page contains no current scholarly academic resources, only internet webpages or no reference page. Lack of APA guidelines for references provided or in-text citations./ 5 pts
HOW TO WORK ON THIS ASSIGNMENT (EXAMPLE ESSAY / DRAFT)
First and foremost, it’s crucial to acquire as much data as you can from the patient, their family, and their medical records. To make sure you cover every important topic, use the Graduate Comprehensive Psychiatric Evaluation Template that is given. Include the patient’s primary complaint, demographics, history of their current illness (including the 8 dimensions of the problem), review of systems, medications, allergies, prior medical history, prior surgical history, prior family psychiatric history, psychiatric history, social history, labs, and screening tools, vital signs, focused physical examination, and mental status examination.
Use the OLD CARTS or PQRST approach to collect information on the problem for the subjective data section (S), and make careful to include a direct statement from the patient regarding their presenting problem. Be meticulous in your research to learn about the patient’s medications, allergies, medical history, etc. for the objective data section (O). Your assessment and treatment plan should be based on current clinical recommendations, such as the NIH Clinical recommendations or the APA Clinical Guidelines. Include at least four recent scholarly journal articles (published within the last five years) or primary legal sources (statutes, court decisions) in your paper, and cite them using APA style, 7th edition.
Give a primary diagnosis and two alternative diagnoses, together with ICD-10 and DSM-5 codes, for the evaluation section (A). Provide medication and non-medication treatment plans, screening and diagnostic tools, patient and family education, referrals, and follow-up for the plan section (P).
Finally, make sure you are addressing all relevant topics and fulfilling the criteria for an excellent evaluation by using the accompanying rubric.
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