Comprehensive Psychiatric Evaluation Template With Psychotherapy Note
please see all attachments as this assignment will be for an initial psych evaluation and should be on a patient with multiple medical conditions and the prescribed medication should not be a med patient is already taking.
Comprehensive Psychiatric Evaluation Template
With Psychotherapy Note
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 (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, Dementia
Exposures:
Immunization HX:
Review of Systems (at least 3 areas per system):
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:
|
Psychotherapy Note |
|
Therapeutic Technique Used: |
|
Session Focus and Theme: |
|
Intervention Strategies Implemented: |
|
Evidence of Patient Response: |
Plan:
Differential Diagnoses
1.
2.
Principal Diagnoses
1.
2.
Plan:
Diagnosis #1
Diagnostic Testing/Screening:
Pharmacological Treatment:
Non-Pharmacological Treatment:
Patient/Family Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Diagnosis #2
Diagnostic Testing/Screening Tool:
Pharmacological Treatment:
Non-Pharmacological Treatment:
Patient/Family 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. 2272022 LM
image1.png
,
Psychiatric/Psychotherapy SOAP Note Rubric
|
Criteria |
Ratings |
Points |
|||
|
Chief Complaint (Reason for seeking health care) – S |
4 to >3.0 points Exemplary Includes a direct quote from patient about presenting problem. |
3 to >2.0 points Distinguished Includes a direct quote from patient and other unrelated information. |
2 to >0.0 points Developing Includes information but information is NOT a direct quote. |
0 points Novice Information is completely missing. |
4 points |
|
Demographics – S |
2 points Exemplary Begins with patient initials, age, race, ethnicity, and gender (5 demographics). |
1.5 points Distinguished Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity, and gender). |
1 points Developing Begins with 3 or less patient demographics (patient initials, age, race, ethnicity, and gender). |
0 points Novice Information is completely missing. |
2 points |
|
History of the Present Illness (HPI) – S |
5 to >3.0 points Exemplary Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity). |
3 to >2.0 points Distinguished Includes the presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity). |
2 to >1.0 points Developing Includes the presenting problem and 4 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity). |
1 to >0 points Novice The presenting problem is not clearly stated and/or there are < 4 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity). |
5 points |
|
Allergies – S |
2 points Exemplary Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy). |
1.5 points Distinguished If allergies are present, student does not list each type of drug, environmental factor, herbal, food, latex name and include severity of allergy OR description of the allergy. |
1 points Developing If allergies are present, student only lists the type of allergy and omits the name of the allergy. |
0 points Novice Information is completely missing. |
2 points |
|
Review of Systems (ROS) – S |
5 to >3.0 points Exemplary Includes a minimum of 3 assessments for each body system, assesses at least 9 body systems directed to chief complaint, AND uses the words “admits” and “denies.” |
3 to >2.0 points Distinguished Includes 3 or fewer assessments for each body system, assesses 5-8 body systems directed to chief complaint, AND uses the words “admits” and “denies.” |
2 to >0.0 points Developing Includes 3 or fewer assessments for each body system, and assesses less than 5 body systems directed to chief complaint, OR student does not use the words “admits” and “denies.” |
0 points Novice Information is completely missing. |
5 points |
|
Vital Signs – O |
2 points Exemplary Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain). |
1.5 points Distinguished Includes at least 6 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain). |
1 points Developing Includes at least 4 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain). |
0 points Novice Information is completely missing. |
2 points |
|
Labs, Diagnostic Tests and Screening Tools – O |
3 points Collepals.com Plagiarism Free Papers Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers. Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS Why Hire Collepals.com writers to do your paper? Quality- We are experienced and have access to ample research materials. We write plagiarism Free Content Confidential- We never share or sell your personal information to third parties. Support-Chat with us today! We are always waiting to answer all your questions.  All Rights Reserved Terms and Conditions |