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Comprehensive Psychiatric Evaluation Template
Essay Instructions:
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. Table 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 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.”
Graduate Mental Status Exam Guide - Comprehensive Psychotherapy Evaluation.docx Download Graduate Mental Status Exam Guide - Comprehensive Psychotherapy Evaluation.docx
Graduate Psychiatric Note Template
Essay Sample Content Preview:
Comprehensive Psychiatric Evaluation Template
With Psychotherapy Note
Encounter date: _Friday 15th July 2022_______________________
Patient Initials: _M. K._____ Gender: M/F/Transgender _Female___ Age: _23 years____ Race: _White____ Ethnicity _Polish___
Reason for Seeking Health Care: _The patient was found unconscious but stable after taking an overdose of benzodiazepines and opioids. After receiving treatment for the drug overdose (the opioids belonged to her boyfriend), she agreed to receive professional treatment for her depressive and psychotic symptoms. Her sister accompanied her to the clinic. The patient reported that, “This is my third suicide attempt. My life has spiraled out of control and I want to get back on track. I have tried therapy before but it didn’t work. I am out of options now and I want to give it another shot”.
HPI:_Ms. Kozlowska is a 23-year-old white female who has been struggling with mental health issues since she was a teenager. The patient states that her depressive symptoms started around the time she was turning fifteen: “I remember becoming irritable and sad shortly before my fifteenth birthday. I would cry myself to sleep and often think of dying. Our father had recently passed away in a car accident, we were close you know. You know, he liked watching the Red Sox”. Her step-sister (45 years) chimed in: “Everyone expected my younger sister to be happy on her birthday. I remember our grandparents had flown in all the way from Poland and we were all excited for her. We spent a great deal of time decorating the house. We wanted her to be happy given how affected she was about the death of her father. I was thirty then and already married. I understood death. She didn’t. Turned out, she had no interest in her birthday and stayed miserable the whole day, no matter what we did. Her mood swings lasted for several weeks at a time after that. Chalked it down to being a spoiled American teenager”. The patient admits to not getting along with her mother or even her sister during that period: “Everyone thought I was acting all childish. My parents were immigrants who worked hard and true to raise us. My mother was very demanding and expected me to get straight A’s in school like my sister. I felt like the black sheep when I could not”. The patient reports that her periods of severe depression were followed by hyperexcitement: “I would steal my mother’s car and credit card during the weekend and hang out with my high school friends. We spent a lot on weed and booze during our frequent road trips. Oh, what jolly times they were”. The patient’s sister reports a time when they had to pay a hefty fine for her release after she was arrested for driving under the influence in another state. Their mother was so incensed that she grounded her for three months: “That’s when I thought about swallowing the bottle of antidepressants my mother kept in her medicine cabinet. She always thought she was so sleek with that blonde hair”. Although this attempt at killing herself was meant to “punish” her mother and make her “look bad”, Ms. Kozlowska admits to ingesting the Prozac pills because she had read somewhere that they were “happy pills”. Fortunately, her mother walked in on her just as she had finished swallowing the pills and rushed her to hospital. “I had an even more acrimonious relationship with my mother after that. She told me that I had let the whole family down and disgraced my father’s memory. I had just turned eighteen and I remember I had a pony for a pet. Can you imagine that?”. The patient left her home in Connecticut for New York to do accounting. Although her sister was happy for her, “my mother less so, she thought accounting was not as marketable as medicine. My sister is a surgeon at Johns Hopkins. I resolved to cut all contact with her and chart my own path. She always thinks I am an underachiever. The nerve in her”. Her new-found freedom in college saw her enter into several relationships which she termed as “fleeting and meaningless”. These “flings” never lasted more than a few months and always ended tragically. She remembers her boyfriends labeling her as “aggressive”, “impossible”, “manipulative”, and “demented”. These “hurtful” breakups saw her turn to prescription alcohol to “dull the senses that just wouldn’t shut”. “My life was hectic then, I had these periods of severe depression and just as I was lifting up, my boyfriend dumps me and then I have several essays due. I was so alone and miserable. I wonder what my boyfriend is doing right now”. The pressure of keeping up with school work, maintaining a meaningful relationship, all while controlling her emotions saw her become a perennial drunkard, something she managed to conceal from her sister. “I would talk with my sister every week but I was careful to conceal my drug dependency. I asked her for money a lot. She was earning a good salary. I could tell from her expensive handbags.”. Besides her sister, her social circle included a few classmates, whom she claims they got along relatively well. “I have these three classmates whom I met at a support group. I went there because I wanted someone, someone I could be honest with. We never talked much before then but after sharing our stories we remained inseparable, even after college. They are envious of my beauty and intelligence, but I think deep down they like me. It’s so nice to have people who worship and care for you, yes? They saved my life, you know, during my second suicide attempt”. Ms. Kozlowska tried to take her life away after the end of her longest relationship. “My boyfriend left me after seven months together. I thought this was it, I had found my love, and then he leaves without a word. Just a text. I felt so betrayed and angry. Anyway, I tried slashing my wrists. I think it was stupid, I should have dumped him a long time ago. I don’t know what I ever saw in him”. Her three classmates chanced to call at her residence and found her unconscious. They rushed her to hospital and informed the patient’s sister, who later suggested that she see a psychiatrist. Ms. Kozlowska states that she only agreed to go because she was still dependent on her sister for her upkeep. She was reluctant to share everything with “a stranger who kept ogling at me the entire time. He was such a loser and reeked of cigarettes. My father used to smoke, you know. I can tell a smoker better than anyone”. The patient was diagnosed as having major depressive disorder and treated with a combination of antidepressant medications and talk therapy. The patient confesses that the medications she received did not help and only increased the regularity of “my highs and lows”. “I didn’t say anything to my sister because I did not want to bother her any more. She had a busy job and could only spend a few days in New York before flying back to Maryland. I felt like I was completely incapable of growing up. Maryland is quite warm at this time of the year”. The patient’s depression was further worsened by the fact that she had difficulty finding a job as an accountant. Ms. Kozlowska’s periods of improvement between depressive events became fewer and after another failed interview, she decided that she had had enough. “That is when I took my boyfriend’s pills. I later woke up in hospital. We talked a great deal with my sister, who was with me until I got discharged. I want to change my life. I have to go to Paris before I die. Always wanted to.”
SI/HI: The patient has recurrent thoughts of committing suicide. She reports acting on them on three separate occasions.
Sleep: The patient reports sleeping very little: “I hate sleep, it is not much fun”.
Appetite: Poor: “I have a poor appetite; my current boyfriend has to force me to finish anything. So cruel”.
Allergies (Drug/Food/Latex/Environmental/Herbal): The patient has a severe allergic reaction to pollen, especially when it comes into contact with her nose, eyes, throat, and mouth
Current perception of Health: Excellent Good Fair Poor
Psychiatric History:
Inpatient hospitalizations:
Date
Hospital
Diagnoses
Length of Stay
3rd May 2014
University of Cincinnati Medical Center
Drug overdose
5 days
6th November 2021
Bellevue Hospital
Major depressive disorder
15 days
Outpatient psychiatric treatment:
Date
Hospital
Diagnoses
Length of Stay
22nd November 2021
Bellevue Hospital
Major depressive disorder
6 weeks
Detox/Inpatient substance treatment:
Date
Hospital
Diagnoses
Length of Stay
History of suicide attempts and/or self injurious behaviors: The patient has attempted suicide three times before this clinical encounter.
Past Medical History
* Major/Chronic Illnesses: The patient has asthma and was diagnosed with the condition at 8 years old (current)
* Trauma/Injury: Treated for a broken leg after falling off a swing at 6 years old.
* Hospitalizations: Hospitalized for broken leg in 2005 and for attempted suicides in 2014 and 2021.
Past Surgical History: The patient had a surgery in 2005 to realign and fix her broken leg.
Current psychotropic medications:
Antidepressants and anti-anxiety medications
Current prescription medications:
Zoloft delivered orally at 50 mg per day; Xanax delivered orally at 4 mg per day; and Ativan delivered orally at 2 mg two times per day
OTC/Nutritionals/Herbal/Complementary therapy:
Substance use: (alcohol, marijuana, cocaine, caffeine, cigarettes)
Substance
Amount
Frequency
Length of Use
Alcohol
6 drinks per day
Daily
3 years
Family Psychiatric History: The patient reports that her mother had a history of depression that was treated with Prozac. Her step-sister confirms this and remembers a time (shortly before she re-married) when she attempted suicide. The death of her first husband (her father) devastated her so much that she tried to drive over a cliff with her while drunk. She received treatment for major depressive disorder and has been okay ever since she decided to start another family. Even after her second husband died, she has remained relatively stable although she has periodic depressive phases when she becomes “distant” and “forlorn”. Other than this, there has been nothing out of the ordinary. She further reports that her step-father’s family had a history of bipolar disorder. Her two uncles (both deceased) were diagnosed with bipolar as was one of her aunts, who is currently situated in an elderly home. Family psychiatric history is otherwise negative. There is no other case of hospitalization, psychiatric disorder, or suicidal behaviors.
Social History
Lives: Single family House/Condo/ with stairs: Lives in a rented apartment with her boyfriend Marital Status: Engaged
Education: College
Employment Status: Works part-time at a bookshop. Struggling financially and relying on her boyfriend for upkeep. Current/Previous occupation type: Worked as an accountant for a non-governmental organization that closed down just three months after starting.
Exposure to: Smoke: No ETOH: Yes Recreational Drug Use: No
Sexual Orientation: Heterosexual Sexual Activity: The patient is currently in an intimate relationship and is living with her boyfriend Contraception Use: Irregular
Family Composition: Family/Mother/Father/Alone: The patient’s father passed away when she was fourteen. She maintains a close relationship with her step-sister and has never spoken to her mother since she was eighteen. She has no other siblings.
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx): The patient describes her childhood memories with her father as “some of the happiest of my life”. “We would go on fishing trips during the weekends. I was very dependent on my father more than my mother from a very young. He worked as a factory manager in another state and would be gone for several weeks. I would get separation anxiety every time he started packing his red briefcase for work. A red briefcase of all the colors, he was passionate about everything”. The patient didn’t get along with her mother and c...
With Psychotherapy Note
Encounter date: _Friday 15th July 2022_______________________
Patient Initials: _M. K._____ Gender: M/F/Transgender _Female___ Age: _23 years____ Race: _White____ Ethnicity _Polish___
Reason for Seeking Health Care: _The patient was found unconscious but stable after taking an overdose of benzodiazepines and opioids. After receiving treatment for the drug overdose (the opioids belonged to her boyfriend), she agreed to receive professional treatment for her depressive and psychotic symptoms. Her sister accompanied her to the clinic. The patient reported that, “This is my third suicide attempt. My life has spiraled out of control and I want to get back on track. I have tried therapy before but it didn’t work. I am out of options now and I want to give it another shot”.
HPI:_Ms. Kozlowska is a 23-year-old white female who has been struggling with mental health issues since she was a teenager. The patient states that her depressive symptoms started around the time she was turning fifteen: “I remember becoming irritable and sad shortly before my fifteenth birthday. I would cry myself to sleep and often think of dying. Our father had recently passed away in a car accident, we were close you know. You know, he liked watching the Red Sox”. Her step-sister (45 years) chimed in: “Everyone expected my younger sister to be happy on her birthday. I remember our grandparents had flown in all the way from Poland and we were all excited for her. We spent a great deal of time decorating the house. We wanted her to be happy given how affected she was about the death of her father. I was thirty then and already married. I understood death. She didn’t. Turned out, she had no interest in her birthday and stayed miserable the whole day, no matter what we did. Her mood swings lasted for several weeks at a time after that. Chalked it down to being a spoiled American teenager”. The patient admits to not getting along with her mother or even her sister during that period: “Everyone thought I was acting all childish. My parents were immigrants who worked hard and true to raise us. My mother was very demanding and expected me to get straight A’s in school like my sister. I felt like the black sheep when I could not”. The patient reports that her periods of severe depression were followed by hyperexcitement: “I would steal my mother’s car and credit card during the weekend and hang out with my high school friends. We spent a lot on weed and booze during our frequent road trips. Oh, what jolly times they were”. The patient’s sister reports a time when they had to pay a hefty fine for her release after she was arrested for driving under the influence in another state. Their mother was so incensed that she grounded her for three months: “That’s when I thought about swallowing the bottle of antidepressants my mother kept in her medicine cabinet. She always thought she was so sleek with that blonde hair”. Although this attempt at killing herself was meant to “punish” her mother and make her “look bad”, Ms. Kozlowska admits to ingesting the Prozac pills because she had read somewhere that they were “happy pills”. Fortunately, her mother walked in on her just as she had finished swallowing the pills and rushed her to hospital. “I had an even more acrimonious relationship with my mother after that. She told me that I had let the whole family down and disgraced my father’s memory. I had just turned eighteen and I remember I had a pony for a pet. Can you imagine that?”. The patient left her home in Connecticut for New York to do accounting. Although her sister was happy for her, “my mother less so, she thought accounting was not as marketable as medicine. My sister is a surgeon at Johns Hopkins. I resolved to cut all contact with her and chart my own path. She always thinks I am an underachiever. The nerve in her”. Her new-found freedom in college saw her enter into several relationships which she termed as “fleeting and meaningless”. These “flings” never lasted more than a few months and always ended tragically. She remembers her boyfriends labeling her as “aggressive”, “impossible”, “manipulative”, and “demented”. These “hurtful” breakups saw her turn to prescription alcohol to “dull the senses that just wouldn’t shut”. “My life was hectic then, I had these periods of severe depression and just as I was lifting up, my boyfriend dumps me and then I have several essays due. I was so alone and miserable. I wonder what my boyfriend is doing right now”. The pressure of keeping up with school work, maintaining a meaningful relationship, all while controlling her emotions saw her become a perennial drunkard, something she managed to conceal from her sister. “I would talk with my sister every week but I was careful to conceal my drug dependency. I asked her for money a lot. She was earning a good salary. I could tell from her expensive handbags.”. Besides her sister, her social circle included a few classmates, whom she claims they got along relatively well. “I have these three classmates whom I met at a support group. I went there because I wanted someone, someone I could be honest with. We never talked much before then but after sharing our stories we remained inseparable, even after college. They are envious of my beauty and intelligence, but I think deep down they like me. It’s so nice to have people who worship and care for you, yes? They saved my life, you know, during my second suicide attempt”. Ms. Kozlowska tried to take her life away after the end of her longest relationship. “My boyfriend left me after seven months together. I thought this was it, I had found my love, and then he leaves without a word. Just a text. I felt so betrayed and angry. Anyway, I tried slashing my wrists. I think it was stupid, I should have dumped him a long time ago. I don’t know what I ever saw in him”. Her three classmates chanced to call at her residence and found her unconscious. They rushed her to hospital and informed the patient’s sister, who later suggested that she see a psychiatrist. Ms. Kozlowska states that she only agreed to go because she was still dependent on her sister for her upkeep. She was reluctant to share everything with “a stranger who kept ogling at me the entire time. He was such a loser and reeked of cigarettes. My father used to smoke, you know. I can tell a smoker better than anyone”. The patient was diagnosed as having major depressive disorder and treated with a combination of antidepressant medications and talk therapy. The patient confesses that the medications she received did not help and only increased the regularity of “my highs and lows”. “I didn’t say anything to my sister because I did not want to bother her any more. She had a busy job and could only spend a few days in New York before flying back to Maryland. I felt like I was completely incapable of growing up. Maryland is quite warm at this time of the year”. The patient’s depression was further worsened by the fact that she had difficulty finding a job as an accountant. Ms. Kozlowska’s periods of improvement between depressive events became fewer and after another failed interview, she decided that she had had enough. “That is when I took my boyfriend’s pills. I later woke up in hospital. We talked a great deal with my sister, who was with me until I got discharged. I want to change my life. I have to go to Paris before I die. Always wanted to.”
SI/HI: The patient has recurrent thoughts of committing suicide. She reports acting on them on three separate occasions.
Sleep: The patient reports sleeping very little: “I hate sleep, it is not much fun”.
Appetite: Poor: “I have a poor appetite; my current boyfriend has to force me to finish anything. So cruel”.
Allergies (Drug/Food/Latex/Environmental/Herbal): The patient has a severe allergic reaction to pollen, especially when it comes into contact with her nose, eyes, throat, and mouth
Current perception of Health: Excellent Good Fair Poor
Psychiatric History:
Inpatient hospitalizations:
Date
Hospital
Diagnoses
Length of Stay
3rd May 2014
University of Cincinnati Medical Center
Drug overdose
5 days
6th November 2021
Bellevue Hospital
Major depressive disorder
15 days
Outpatient psychiatric treatment:
Date
Hospital
Diagnoses
Length of Stay
22nd November 2021
Bellevue Hospital
Major depressive disorder
6 weeks
Detox/Inpatient substance treatment:
Date
Hospital
Diagnoses
Length of Stay
History of suicide attempts and/or self injurious behaviors: The patient has attempted suicide three times before this clinical encounter.
Past Medical History
* Major/Chronic Illnesses: The patient has asthma and was diagnosed with the condition at 8 years old (current)
* Trauma/Injury: Treated for a broken leg after falling off a swing at 6 years old.
* Hospitalizations: Hospitalized for broken leg in 2005 and for attempted suicides in 2014 and 2021.
Past Surgical History: The patient had a surgery in 2005 to realign and fix her broken leg.
Current psychotropic medications:
Antidepressants and anti-anxiety medications
Current prescription medications:
Zoloft delivered orally at 50 mg per day; Xanax delivered orally at 4 mg per day; and Ativan delivered orally at 2 mg two times per day
OTC/Nutritionals/Herbal/Complementary therapy:
Substance use: (alcohol, marijuana, cocaine, caffeine, cigarettes)
Substance
Amount
Frequency
Length of Use
Alcohol
6 drinks per day
Daily
3 years
Family Psychiatric History: The patient reports that her mother had a history of depression that was treated with Prozac. Her step-sister confirms this and remembers a time (shortly before she re-married) when she attempted suicide. The death of her first husband (her father) devastated her so much that she tried to drive over a cliff with her while drunk. She received treatment for major depressive disorder and has been okay ever since she decided to start another family. Even after her second husband died, she has remained relatively stable although she has periodic depressive phases when she becomes “distant” and “forlorn”. Other than this, there has been nothing out of the ordinary. She further reports that her step-father’s family had a history of bipolar disorder. Her two uncles (both deceased) were diagnosed with bipolar as was one of her aunts, who is currently situated in an elderly home. Family psychiatric history is otherwise negative. There is no other case of hospitalization, psychiatric disorder, or suicidal behaviors.
Social History
Lives: Single family House/Condo/ with stairs: Lives in a rented apartment with her boyfriend Marital Status: Engaged
Education: College
Employment Status: Works part-time at a bookshop. Struggling financially and relying on her boyfriend for upkeep. Current/Previous occupation type: Worked as an accountant for a non-governmental organization that closed down just three months after starting.
Exposure to: Smoke: No ETOH: Yes Recreational Drug Use: No
Sexual Orientation: Heterosexual Sexual Activity: The patient is currently in an intimate relationship and is living with her boyfriend Contraception Use: Irregular
Family Composition: Family/Mother/Father/Alone: The patient’s father passed away when she was fourteen. She maintains a close relationship with her step-sister and has never spoken to her mother since she was eighteen. She has no other siblings.
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx): The patient describes her childhood memories with her father as “some of the happiest of my life”. “We would go on fishing trips during the weekends. I was very dependent on my father more than my mother from a very young. He worked as a factory manager in another state and would be gone for several weeks. I would get separation anxiety every time he started packing his red briefcase for work. A red briefcase of all the colors, he was passionate about everything”. The patient didn’t get along with her mother and c...
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