Comprehensive Psychiatric Evaluation SOAP Note
*/ You can use any patient with a psychiatric issue, this is for a PMHNP clinical class of Psychotherapy.
For this assignment, students will create a written comprehensive psychiatric evaluation of a patient they have seen in the clinic. Each student will use the Graduate Psychotherapy Note Template Download Graduate Psychotherapy Note Template 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 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 ICD-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.”
Submission Instructions:
The paper is to be clear and concise and students will lose points for improper grammar, punctuation and misspelling.
The paper should be formatted per current APA and 8-10 pages in length, excluding the title, abstract and references page. Incorporate a minimum of 5 current (published within last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work.
Title
Your name
Subject and Section
Professor’s Name
Date
Abstract
Understanding the various treatments for every psychological illness is essential for every psychiatric health practitioner. It allows him to assess the patient’s health and well-being and provide the appropriate treatment for her situation. The case presented below is about Patient AJDV seeking help for suicidal ideations before her consultation. An interview with the patient revealed that the leading cause is a combination of family problems, occupational stressors, and personal issues, among others.
Comprehensive Psychiatric Evaluation Template
With Psychotherapy Note
Encounter date: ________________________
Patient Initials: AJDV Gender: M/F/Transgender: F Age: 27 Race: American Ethnicity: American
Reason for Seeking Health Care: “I have been having persistent suicidal thoughts, and I have been planning how to kill myself for quite some time. I am afraid of what I can do to myself.”
HPI: Two months before consultation, the patient started to work as a part-time nurse practitioner in a private hospital in her neighborhood due to financial difficulties at home. She had to pay the debt that she had in college, and she also needed to support her sick mother, who was receiving palliative care secondary to liver cirrhosis. The expenses exceeded the family's monthly budget, prompting her and her siblings to seek a part-time job to help them pay for their due finances.
Initially, the patient was assigned for the first time to the pediatric department. In contrast, she was previously assigned to the adult and geriatric departments in her previous work as a nurse practitioner. Hence, the tasks were new to her. During the first week of employment, the patient was welcomed by her colleagues, and the tasks and responsibilities were explained in detail patiently by the nursing supervisor. The patient frequently asked questions about the details that she could not understand, such as some of the hospital protocols that were new to her and the use of the updated electronic healthcare system.
Moreover, she frequently asked for guidance with the skills that she was used to, especially in handling pediatric care. During the initial week, her colleagues patiently guided her, welcomed her, and entertained her questions as much as possible. The actions of her colleagues and the entire department delighted her and made her feel like it was her new home apart from her own. There was a turnover of events during the second week, and her colleagues started to treat her differently. The patient stated that "they wanted me to do everything because I was the part-timer and the tasks that I should do were not delineated from theirs." This was exacerbated by the sudden increase in the pediatric cases secondary to the increase in the number of influenza-like illness-associated diseases in the community due to the lack of compliance of the parents in the immunization of their children. Hence, the patient was given many responsibilities that were not included in her initial line of work.
Moreover, the patient spent time mostly with her work and sleeping for approximately 12 hours a day and feeling tired regardless of how much rest she took. Interim history revealed the persistence of symptoms, including the increase in the sleeping hours, lack of the willingness to live, suicidal thoughts, poor appetite, lack of pleasure in her hobbies, and lack of concentration. A few hours before consultation, the patient felt that she wanted to take her life using a knife, called her friend, and told her her plan. The friend immediately called the emergency hotline services, and the patient was rushed to the hospital.
SI/HI: Two weeks prior to consultation, the patient started to have suicidal thoughts, stating that “the world would not change without me and in fact, it might be better off without me.” The patient wanted to die for feeling worthless and the fear of being alone if her mother passed away due to the mother’s chronic illness. During this time, the patient did not have any intent or plan to execute her thoughts. One week prior to consultation, the patient admitted to strategizing how to kill herself with the most minimal pain possible. She devised three situations. First that she would stab her neck on the left common carotid artery to ensure that there would be rapid acute blood loss. Second, she would jump off a cliff, and lastly, she would overdose on drugs. The patient contemplated this for another week while trying to fight her thoughts of death. However, a few hours prior to consultation, the patient decided to execute her suicidal intentions and chose to do the first plan, but she also called her friend a “last cry for help,” as stated by the patient. The patient did not have any homicidal ideations, intent, or plan previously and up to the present.
Sleep: The patient stated that she sleeps most of the time a week, with approximately 12 hours of continuous sleep in a day.
Appetite: The patient does not feel hungry most of the time and only eats once a day and sometimes, not at all. When she eats, she can only finish half a plate of a viand, half a cup of noodles, or half a slice of pizza, stating that she does not have the appetite since she is eating alone.
Allergies (Drug/Food/Latex/Environmental/Herbal): The patient denies any known allergies to food, drug, latex, environment, or herbal medications.Current perception of Health: Excellent Good Fair Poor
Psychiatric History:
Inpatient hospitalizations:
Date
Hospital
Diagnoses
Length of Stay
None
None
Not applicable
Not applicable
Outpatient psychiatric treatment:
Date
Hospital
Diagnoses
Length of Stay
None
None
Not applicable
Not applicable
Detox/Inpatient substance treatment:
Date
Hospital
Diagnoses
Length of Stay
None
None
Not applicable
Not applicable
History of suicide attempts and/or self-injurious behaviors:
The patient denies any history of suicidal attempts and self-injurious behaviors in the past, before the recent incident.
Past Medical History
* Major/Chronic Illnesses. The patient denies any major or chronic illnesses, including hypertension, diabetes mellitus, malignancies, cerebrovascular disease, coronary artery disease, lung, renal, or liver diseases.
* Trauma/Injury: Five years prior to consultation (2017), the patient had a high ankle sprain left after her grand rehearsal for a dance competition. The patient was brought to the emergency room, prescribed Celecoxib 200mg/capsule, 1 capsule twice a day as needed for pain, and referred to physical therapy for rehabilitation. The patient recovered from her injury without complications. This is an inactive diagnosis.
* Hospitalizations: Seven years before consultation (2015), the patient was hospitalized due to community-acquired pneumonia-moderate risk and was prescribed unrecalled antibiotics of unrecalled dose. The patient recovered without complications. This is an inactive diagnosis.
Past Surgical History: The patient denies undergoing any surgical interventions.
Current psychotropic medications: None
Current prescription medications: None
OTC/Nutritional/Herbal/Complementary therapy: None
Substance use: (alcohol, marijuana, cocaine, caffeine, cigarettes)
Substance
Amount
Frequency
Length of Use
Alcoholic beverages
2 to 3 bottles of beer or 1 to 2 glasses of vodka
Once or twice a month
2010-2022
Caffeine
1 8-ounce cup
Two to three times a week
2015-2022
The patient denies any recreational use of drugs such as cocaine and marijuana and denies smoking cigarettes or vaping.
Family Psychiatric History: The patient’s father had a major depressive disorder, recurrent, and died from suicide in 2012. The patient’s aunt, her father’s sister, was diagnosed with bipolar disorder and currently has suicidal ideations with no attempts. The patient’s mother, two sisters, and mother’s only sister have no genetic diseases, major depressive disorder, bipolar disorder, other mood disorders, and suicidal ideations or attempts.
Social History
Lives: Single-family House/Condo/ with stairs: Alone in a studio-type apartment on the second floor, using the stairs, without elevators Marital Status: Single
Education: Bachelor of Science in Nursing
Employment Status: Active Current/Previous occupation type: The patient currently works as a full-time writer in a United States-based company, spending approximately 8 to 10 hours of work daily, including weekends. The patient was previously employed as a part-time nurse practitioner in a private hospital, working approximately 8 hours a day, excluding weekends.
Exposure to: Smoke: None ETOH: Occasional Recreational Drug Use: None
Sexual Orientation: Homosexual Sexual Activity: Inactive Contraception Use: None
Family Composition: Family/Mother/Father/Alone: The patient’s mother is alive and has liver cirrhosis, while her father died from a suicide ten years ago. The patient is the 2nd among three siblings.
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse ...