07 Jun Compose a written comprehensive psychiatric evaluation

Psychiatric SOAP Note Template

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: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____

Exposures:

Immunization HX:

Review of Systems:

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:

Significant Data/Contributing Dx/Labs/Misc.

Plan:

Differential Diagnoses

1.

2.

Principal Diagnoses

1.

2.

Plan

Diagnosis #1

Diagnostic Testing/Screening:

Pharmacological Treatment:

Non-Pharmacological Treatment:

Education:

Referrals:

Follow-up:

Anticipatory Guidance:

Diagnosis #2

Diagnostic Testingg/Screenin:

Pharmacological Treatment:

Non-Pharmacological Treatment:

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. 10162021 LM

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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.  

Reminder: It is important that you complete this assessment using your critical thinking skills.  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  Download Graduate Mental Status Exam Guide   

Successfully Capture HPI Elements in Psychiatry E/M NotesLinks to an external site. 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/

 

Submission Instructions: 

· Upload your completed Comprehensive Psychiatric Evaluation as a word document. It will be assessed through Turnitin.