Major Depressive Disorder Psychiatric SOAP Note

Step 1: You will use the Graduate Comprehensive Psychiatric Evaluation Template Download Graduate Comprehensive Psychiatric Evaluation Templateto: 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 3. Please remember your History of Present Illness (HPI) should tell a story about your patient Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity). The HPI and history should support the patient’s DSM5-TR diagnosis at all times. 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. • • Psychiatric Assessment of Infants and ToddlersLinks to an external site. Psychiatric Assessment of Children and AdolescentsLinks to an external site.