Each student will create a focused SOAP note or PowerPoint presentation. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive psychiatric SOAP note or PowerPoint is to be written using the attached template below. Do not provide a voiceover or video for the PowerPoint. Only the information asked in the video will be used for grading.
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). Click hereLinks to an external site. for more details
O =
Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; 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 presentation.
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 GuideDownload Graduate Mental Status Exam Guide
Submission Instructions:
In addition to the video demonstrating proficiency in completing a comprehensive psychiatric evaluation, students must upload a comprehensive written submission.
The written submission should be limited to PowerPoint 10-12 slides or a comprehensive psychiatric note and include all sections of the SOAP note listed above.
The comprehensive psychiatric examination is original work and logically organized, formatted, and cited in the current APA style, including citation of references. Incorporate a minimum of four current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work. Journal articles and books should be referenced according to APA style, 7th Edition (the library has a copy of the APA Manual).
Students must wear their lab coats, display their STU or other identification, and conduct the video in a professional setting, or the presentation will not be graded.
Complete and submit the assignment by 11:59 PM ET Sunday
riteria Ratings Pts
Establishing Rapport – Professionalism
view longer description
4 to >3 pts
Exemplary
Introduced self, including (name and role, student PMHNP).
3 to >0 pts
Developing
Introduced self, including but fails to state role (student PMHNP).
0 pts
Novice
Does not introduce him/herself (name and role).
/ 4 pts
Establishing Rapport – Professionalism
view longer description
2 to >1 pts
Exemplary
Begins interview by identifying patient and caregiver’s by name.
1 to >0 pts
Developing
Begins interview by identifying patient only.
0 pts
Novice
Begins interview by identifying caregiver only.
/ 2 pts
Chief Complaint (Reason for seeking health care) – S
view longer description
4 to >3 pts
Exemplary
Includes a direct quote from patient about presenting problem.
3 to >0 pts
Developing
Includes information but information is NOT a direct quote.
0 pts
Novice
Information is completely missing.
/ 4 pts
History of the Present Illness (HPI) – S
view longer description
4 to >3 pts
Exemplary
Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity).
3 to >0 pts
Developing
Includes the presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity).
0 pts
Novice
The presenting problem is not clearly stated and/or there are 4 pts
Exemplary
Includes a minimum of 3 assessments for each body system, assesses at least 9 body systems directed to chief complaint, AND uses the words “admits” and “denies.”
4 to >0 pts
Developing
Includes 2 or fewer assessments for each body system, and assesses less than 5 body systems directed to chief complaint, OR student does not use the words “admits” and “denies.”
0 pts
Novice
Information is completely missing.
/ 5 pts
Vital Signs – O
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3 to >2 pts
Exemplary
Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)
2 to >0 pts
Developing
Includes 7 or fewer vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)
0 pts
Novice
Information is completely missing.
/ 3 pts
Labs, Diagnostic Tests and Screening Tools – O
view longer description
3 to >2 pts
Exemplary
Includes a list of the labs, diagnostic tests or screening tools reviewed at the visit, values of lab results or screening tools, and highlights abnormal values, OR acknowledges no labs/diagnostic tests were reviewed.
2 to >0 pts
Developing
Includes a list of the labs, diagnostic tests, or screening tools reviewed at the visit but does not include the values of the results or highlight abnormal values.
0 pts
Novice
Information is completely missing.
/ 3 pts
Medications-S
view longer description
4 to >3.2 pts
Exemplary
Includes a list of all of the patient reported psychiatric and medical medications and the diagnosis for the medication (including name, dose, route, frequency of the prescribed medications, herbal or over the counter medications).
3.2 to >0 pts
Developing
Includes a list of some of the patient reported psychiatric and/or medical medications and the diagnosis for the medication (omits the dose, route, frequency of the prescribed medications, herbal or over the counter medications).
0 pts
Novice
Information is completely missing.
/ 4 pts
Past Medical History-S
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3 to >2 pts
Exemplary
Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current
2 to >1 pts
Distinguished
Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current.
1 to >0 pts
Developing
Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current.
0 pts
Novice
Information is completely missing.
/ 3 pts
Past Psychiatric History-S
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5 to >4 pts
Exemplary
Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), and year of diagnosis.
4 to >0 pts
Developing
Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), and does not include the year of diagnosis.
0 pts
Novice
Information is completely missing.
/ 5 pts
Family Psychiatric History-S
view longer description
3 to >2 pts
Exemplary
Includes an assessment of at least 6 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder and history of suicidal attempts
2 to >0 pts
Developing
Includes an assessment of at least 3 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder and history of suicidal attempts
0 pts
Novice
Information is completely missing.
/ 3 pts
Social History-S
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3 to >2 pts
Exemplary
Includes all 11 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexual activity, developmental history, contraceptive use/pregnancy status, and living situation.
2 to >0 pts
Developing
Includes 6-10 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexual activity, developmental history, contraceptive use/pregnancy status, and living situation.
0 pts
Novice
Information is completely missing.
/ 3 pts
Mental Status Exam-O
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15 to >12 pts
Exemplary
Includes greater than 9 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with detailed descriptions for each area
12 to >0 pts
Developing
Includes 6-9 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with some descriptions for each area
0 pts
Novice
Includes 5 or fewer components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) OR detailed descriptions is not included for each area
/ 15 pts
Primary Diagnoses – A
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5 to >4 pts
Exemplary
Includes a clear outline of the accurate principal diagnosis based on DSM5-TR
4 to >0 pts
Developing
Includes a medical diagnosis based as the principal diagnosis OR the diagnosis is not a DSM5-TR diagnosis
0 pts
Novice
Information is completely missing.
/ 5 pts
Differential Diagnoses – A
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3 to >2 pts
Exemplary
Includes at least 2 differential diagnoses for the principal diagnosis based on DSM5-TR
2 to >0 pts
Developing
Includes 1 differential diagnosis for the principal diagnosis OR the diagnosis is not a DSM5-TR diagnosis
0 pts
Novice
Information is completely missing.
/ 3 pts
Outcome Labs/Screening Tools – O
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3 to >2 pts
Exemplary
Includes appropriate diagnostic/lab testing or screening tool 100% of the time OR acknowledges “no diagnostic testing or screening tool clinically required at this time”
2 to >0 pts
Developing
Includes appropriate diagnostic testing less than 50% of the time.
0 pts
Novice
Information is completely missing.
/ 3 pts
Treatment
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6 to >5 pts
Exemplary
Includes a detailed pharmacologic and non pharmacological treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the following: drug/vitamin/herbal name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. For non-pharmacological treatment, includes: treatment name, frequency, duration. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.
5 to >0 pts
Developing
Includes a detailed pharmacologic and non pharmacological treatment plan for each of the diagnoses listed under “assessment”. The plan includes 4 of the following: drug/vitamin/herbal name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. Non-pharmacological treatment NOT included. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.
0 pts
Novice
Information is completely missing.
/ 6 pts
Patient/Family Education – P
view longer description
5 to >3 pts
Exemplary
Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives.
3 to >0 pts
Developing
Includes 1-2 strategies to promote and develop skills for managing their illness and at least 1 self-management method on how to incorporate healthy behaviors into their lives.
0 pts
Novice
Information is completely missing.
/ 5 pts
Professionalism
view longer description
10 to >5 pts
Exemplary
The student summarized/concluded the visit at the end of the appointment, asked if there were questions before concluding appointment, demonstrated active listening. The student gave verbal/nonverbal positive reinforcement, and the information was not obtained in a logical, systematic, orderly progression.
5 to >0 pts
Developing
The student summarized/concluded the visit at the end of the appointment. The student used leading & and why questions and/or medical jargon not actively listen to the patient/parent . The student demonstrated active listening and/or the information was obtained info in logical, systematic, orderly progression.
0 pts
Novice
The student did not summarize/conclude the visit. The student was unprofessional, did not actively listen. The information was not obtained in a logical manner”
