Posted: February 27th, 2025

Comprehensive Psychiatric Evaluation and SOAP Note Development

Comprehensive Psychiatric Evaluation and SOAP Note Guide for Graduate Students

Step 1: You will use the Graduate Comprehensive Psychiatric Evaluation Template to:

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Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.
Ensure that your evaluation is thorough and includes all relevant patient history, symptoms, and clinical findings.

Upload your completed comprehensive psychiatric evaluation as a Word doc. Scanned PDFs will not be accepted.
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.
This presentation will allow you to demonstrate your ability to synthesize clinical information and present it effectively.
See Comprehensive Psychiatric Evaluation Presentation 3 for more details.

SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.
The SOAP format is a structured method for documenting patient encounters and ensures comprehensive care.

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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 DSM-5 codes.

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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 or APA Clinical Guidelines, research articles, and the role of the PMHNP in your evaluation.
Staying updated with evidence-based practices ensures the highest quality of patient care.

Psychiatric Assessment of Infants and Toddlers.

Psychiatric Assessment of Children and Adolescents.

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Reminder: It is important that you complete this assessment using your critical thinking skills.
Critical thinking is essential for accurate diagnosis and effective treatment planning.
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
Successfully Capture HPI Elements in Psychiatry E/M Notes
AAPC Admin. (2013, August 1). Successfully capture HPI elements in psychiatry E/M notes. Advancing the Business of Healthcare. https://www.aapc.com/blog/25848-successfully-capture-hpi-elements-in-psychiatry-em-notes/

Psychiatric SOAP Note Rubric

Suggested Extra References:

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American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Mangione, C.M., Barry, M.J., Nicholson, W.K., Cabana, M., Chelmow, D., Coker, T.R., Davidson, K.W., Davis, E.M., Donahue, K.E., Jaén, C.R. and Kubik, M., 2022. Screening for depression and suicide risk in children and adolescents: US preventive services task force recommendation statement. Jama, 328(15), pp.1534-1542.

National Institute of Mental Health. (2021). Mental Health Information. Retrieved from https://www.nimh.nih.gov/health/topics

Rathod, S., Skórniewska, Z., Engelthaler, T., Fell, B., Sajid, S. and Phiri, P., 2024. Treatment resistant depression: A comparative study of access, pathways, and outcomes between Caucasian and ethnic minority individuals. Journal of Affective Disorders, 352, pp.357-365.

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"Comprehensive Psychiatric Evaluation and SOAP Note Development: A Guide for Graduate Students in Mental Health Practice"

Patient must be 12 years old with depression living in United States

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