us esoap note template attached other is just instructions
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.
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For the Comprehensive Psychiatric 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 Psychiatric Evaluation Presentation 1
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
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.
atatched is the soap note template use apa 7 the dition
