Nursing homework

PsychiatricEvaluationTemplate620L.docx

page1image3861729600

Psychiatric SOAP Note Template

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: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____

Exposures:

Immunization HX:

Review of Systems:

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:

Significant Data/Contributing Dx/Labs/Misc.

Plan:

Differential Diagnoses

1.

2.

Principal Diagnoses

1.

2.

Plan

Diagnosis #1

Diagnostic Testing/Screening:

Pharmacological Treatment:

Non-Pharmacological Treatment:

Education:

Referrals:

Follow-up:

Anticipatory Guidance:

Diagnosis #2

Diagnostic Testingg/Screenin:

Pharmacological Treatment:

Non-Pharmacological Treatment:

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. 10162021 LM

image1.png

ComprehensivePsychiatricevaluationinstructions.docx

Comprehensive Psychiatric Evaluation 1

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

1. Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.

2. Upload your completed comprehensive psychiatric evaluation as a Word doc. Scanned PDFs will not be accepted.

.

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)
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 GuidelinesLinks to an external site. or APA Clinical GuidelinesLinks to an external site. , research articles, and the role of the PMHNP in your evaluation.

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 NotesLinks 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/

PsychiatricEvaluationTemplate620L.docx

page1image3861729600

Psychiatric SOAP Note Template

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: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____

Exposures:

Immunization HX:

Review of Systems:

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:

Significant Data/Contributing Dx/Labs/Misc.

Plan:

Differential Diagnoses

1.

2.

Principal Diagnoses

1.

2.

Plan

Diagnosis #1

Diagnostic Testing/Screening:

Pharmacological Treatment:

Non-Pharmacological Treatment:

Education:

Referrals:

Follow-up:

Anticipatory Guidance:

Diagnosis #2

Diagnostic Testingg/Screenin:

Pharmacological Treatment:

Non-Pharmacological Treatment:

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. 10162021 LM

image1.png

ComprehensivePsychiatricevaluationinstructions.docx

Comprehensive Psychiatric Evaluation 1

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

1. Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.

2. Upload your completed comprehensive psychiatric evaluation as a Word doc. Scanned PDFs will not be accepted.

.

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)
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 GuidelinesLinks to an external site. or APA Clinical GuidelinesLinks to an external site. , research articles, and the role of the PMHNP in your evaluation.

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 NotesLinks 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/

PsychiatricEvaluationTemplate620L.docx

page1image3861729600

Psychiatric SOAP Note Template

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: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____

Exposures:

Immunization HX:

Review of Systems:

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:

Significant Data/Contributing Dx/Labs/Misc.

Plan:

Differential Diagnoses

1.

2.

Principal Diagnoses

1.

2.

Plan

Diagnosis #1

Diagnostic Testing/Screening:

Pharmacological Treatment:

Non-Pharmacological Treatment:

Education:

Referrals:

Follow-up:

Anticipatory Guidance:

Diagnosis #2

Diagnostic Testingg/Screenin:

Pharmacological Treatment:

Non-Pharmacological Treatment:

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. 10162021 LM

image1.png

ComprehensivePsychiatricevaluationinstructions.docx

PsychiatricEvaluationTemplate620L.docx

ComprehensivePsychiatricevaluationinstructions.docx

PsychiatricEvaluationTemplate620L.docx

image1.png

PsychiatricEvaluationTemplate620L.docx

image1.png

ComprehensivePsychiatricevaluationinstructions.docx

PsychiatricEvaluationTemplate620L.docx

image1.png

ComprehensivePsychiatricevaluationinstructions.docx

PsychiatricEvaluationTemplate620L.docx

image1.png

SOAP Note

SOAP Note

SOAP Note

Comprehensive Psychiatric Evaluation 3

Soap Note Psychiatric Evaluation

Comprehensive Psychiatric Evaluation 1

Nursing Homework