St Thomas University Comprehensive Psychotherapy Presentation

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For this assignment, students will create a written comprehensive psychiatric evaluation of a patient they have seen in the clinic. Your preceptor must sign their initials on this document to confirm they have reviewed and acknowledge this patient was seen in their clinic. Each student will use the Graduate Psychotherapy Note Template.docx to create a detailed psychiatric evaluation document. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive psychiatric evaluation is to be written using the attached template below. 

S.O.A.P. TableS – Subjective data: Patient’s Chief Complaint (CC);  History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) (Links to an external site.) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS); Review of Systems (ROS).O – Objective data: Medications; Allergies; Past medical history; Family 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 IDC-10 and DSM5 codes.P – Plan: Pharmacologic and Nonpharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow-up.

Other:?Incorporate current clinical guidelines NIH Clinical Guidelines (Links to an external site.) or APA Clinical Guidelines (Links to an external site.), research articles, and the role of the PMHNP in your presentation.  

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.”