Comprehensive Psychotherapy Evaluation 3
Step 1: You will use the Graduate Comprehensive Psychotherapy Evaluation Template
Download Graduate Comprehensive Psychotherapy Evaluation Template
to:
1. Compose a written comprehensive psychotherapy evaluation of a patient you
have seen in the clinic.
2. Upload your completed comprehensive psychotherapy 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 3 for more
details.
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.
Other: Incorporate current clinical guidelines NIH Clinical Guidelines
Links to an external site.
or APA Clinical Guidelines
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
Links to an external site.
, research articles, and the role of the PMHNP in your evaluation.
• 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 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.
successfully-capture-hpi-elements-in-psychiatry-em-notes/
Patient 12 – Schizophrenia, Paranoid Type
ICD-10: F20.0
Gender: Male
Insurance: Medicare
Ethnicity: Caucasian
Chief Complaint: “People at work are spying and keep looking at me crazy.”
Race: White
Age: 46
Narrative (Procedures): PANSS elevated; MSE: anxious, persecutory delusions, auditory
hallucinations, blunted affect.
3 Principal Diagnoses:
1. Schizophrenia, paranoid type – F20.0
2. Insomnia due to psychotic disorder – F51.05
3. Social Isolation – Z60.4
3 Differentials:
1. Delusional Disorder (F22): Hallucinations present → schizophrenia.
2. Schizoaffective Disorder (F25.1): No mood episodes.
3. MDD w/ Psychotic Features (F32.3): Psychosis independent of mood.
Pharmacological Treatment: Risperidone 2 mg PO BID × 30 days + Benztropine 0.5 mg PO
BID PRN for EPS.
Education: Sedation possible; avoid alcohol; maintain regular follow-up.
RR/Ht/Wt/BMI: RR 18, Ht 5’10”, Wt 165 lb, BMI 23.7 (normal).
HPI: 46-year-old man with chronic paranoia and auditory hallucinations for 3 years. Recently
stopped meds, symptoms worsened. Denies violence or SI. Maintains ADLs with mother’s
supervision.
Sleep: 4 hours, frequent awakenings from fear.
