NUR 640 clinicals

Comprehensive Psychotherapy Evaluation 2

Step 1: You will use the Graduate Comprehensive Psychotherapy Evaluation Template Download Graduate Comprehensive Psychotherapy Evaluation Templateto:

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

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

For the Comprehensive Psychotherapy 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 Psychotherapy Evaluation Presentation 2 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) 

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 

1. 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.   
2. Psychiatric Assessment of Infants and ToddlersLinks to an external site. 

Psychiatric Assessment of Children and AdolescentsLinks to an external site. 

• 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-captu…

.