Comprehensive Psychotherapy Evaluation 2

Psychiatric SOAP Note Rubric 

Comprehensive Psychotherapy Evaluation 2

Based on the following patient:

Principal Diagnosis # 1: Posttraumatic Stress Disorder (F43.10)

I need a second Principal Diagnosis

Chief Complaint: “I keep reliving the ambush and the explosives, I can’t sleep and wake up sweating.”

Clinical Note: Patient is a combat veteran presenting with nightmares, flashbacks, and hypervigilance related to past trauma. He avoids crowded areas and has severe sleep disturbance. Symptoms persist despite current treatment, warranting medication adjustment.

Draft HPI: A 52-year-old White male, retired combat veteran, presents for follow-up of PTSD. He describes severe nightmares, avoidance of reminders, hypervigilance, and intrusive thoughts of combat experiences. He reports that despite adherence to sertraline, he continues to have daily symptoms. His wife notes irritability and emotional detachment. Sleep is disrupted, averaging 3 hours per night. He avoids public places due to anxiety and sits facing doors in restaurants. He denies active suicidal ideation but reports occasional hopelessness. His trauma has significantly impaired his marriage and social life. Previous therapy provided mild benefit, but he discontinued due to discomfort with exposure exercises. He seeks medication adjustment and additional strategies for managing nightmares and insomnia.

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

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.
   • 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 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 Guidelines.

Your assignment will be graded according to the grading rubric!

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: ____________________________________________________________