You will complete a comprehensive psychiatric mental health assessment of a child/adolescent. This should NOT be a patient you have encountered in you
You will complete a comprehensive psychiatric mental health assessment of a child/adolescent. This should NOT be a patient you have encountered in your work but, instead, should be a family member or friend (who gives consent). You should note that all information will be confidential and that their private information will NOT be shared as part of this assignment. Your assessment should be comprehensive, and you should refer to course texts to inform items for inclusion in your assessment. Keep in mind that you will be responsible for covering those areas addressed in the reading assignments up to this point. The documentation should remain HIPAA-compliant even though this is not a real patient. (DO NOT USE REAL PATIENT IDENTIFIERS.) Be sure to include birth and developmental information as well as school and behavior information for the child. Consider cultural, gender, ethnicity, spiritual, and social competencies needed to formulate the best care plan for the patient.
The patient will be referred to as Jane Doe or Jack Doe.
Use the Initial Psychiatric Assessment SOAP Note Template to complete this assignmen
Grading Rubric
Assignment
Criteria
Level III
Level II
Level I
Not Present
Criteria
1
Level III Max Points
Points: 8
Level II Max Points
Points: 6.4
Level I Max Points
Points: 4.8
0 Points
Subjective
Information
●
Complete and concise summary of
pertinent information.
●
Well organized; partial but
accurate summary of pertinent information (>80%).
●
Poorly organized and/or limited
summary of pertinent information (50%-80%); information other than “S”
provided.
●
Does not meet the criteria
Assignment
Criteria
Level III
Level II
Level I
Not Present
Criteria
2
Level III Max Points
Points: 8
Level II Max Points
Points: 6.4
Level I Max Points
Points: 4.8
0 Points
Objective Information
●
Complete and concise summary of pertinent
information.
●
Partial but accurate summary of
pertinent information (>80%).
●
Poorly organized and/or limited
summary of pertinent information (50%-80%); information other than “O”
provided.
●
Does not meet the criteria
Assignment
Criteria
Level III
Level II
Level I
Not Present
Criteria
3
Level III Max Points
Points: 8
Level II Max Points
Points: 6.4
Level I Max Points
Points: 4.8
0 Points
Assessment:
Problem Identification and Prioritization
●
Complete problem list generated
and rationally prioritized; no extraneous information or issues listed.
●
Most problems are identified and
rationally prioritized, including the “main” problem for the case (>80%).
●
Some problems are identified
(50%-80%); incomplete or inappropriate problem prioritization; includes
nonexistent problems or extraneous information included.
●
Does not meet the criteria
Criteria
4
Level III Max Points
Points: 8
Level II Max Points
Points: 6.4
Level I Max Points
Points: 4.8
0 Points
Assessment:
Assessment of Current Psychiatric & Medical Condition(s) or Drug
Therapy-related Problem
●
An optimal and thorough
assessment is present for each problem
●
An assessment is present for
each problem listed but not optimal
●
Assessment is present for 50-80%
of problems
●
Does not meet the criteria
Assignment
Criteria
Level III
Level II
Level I
Not Present
Criteria
5
Level III Max Points
Points: 6
Level II Max Points
Points: 4.8
Level I Max Points
Points: 3.6
0 Points
Assessment: Treatment Goals
●
Appropriate and relevant
therapeutic goals for each identified problem.
●
Appropriate therapeutic goals
for most identified problems (>80%).
●
Appropriate therapeutic goals
for a few identified problems (50%-80%).
●
Less than 50% of problems have
appropriate therapeutic goals.
Assignment
Criteria
Level III
Level II
Level I
Not Present
Criteria
6
Level III Max Points
Points: 6
Level II Max Points
Points: 4.8
Level I Max Points
Points: 3.6
0 Points
Plan: Treatment
Plan
●
Specific, appropriate and
justified recommendations (including drug name, strength, route, frequency,
and duration of therapy) for each identified problem are included.
●
Includes most of the
requirements for each identified problem (>80%).
●
Incomplete and/or inappropriate
for a few identified problems (50%-80%); information other than “P” provided.
●
Less than 50% of problems have
an appropriate and complete treatment plan.
Criteria
7
Level III Max Points
Points: 6
Level II Max Points
Points: 4.8
Level I Max Points
Points: 3.6
0 Points
Plan:
Counseling, Referral, Monitoring &
Follow-up
●
Specific patient education
points, monitoring parameters, follow-up plan and (where applicable) referral
plan for each identified problem.
●
Patient education points, monitoring
parameters, follow-up plan and referral plan (where applicable) for >80%
of identified problems.
●
Patient education points,
monitoring parameters, follow-up plan and referral plan (where applicable)
for a few identified problems (50%-80%).
●
Less than 50% of problems
include appropriate counseling, monitoring, referral and/or follow-up plan.
Maximum Total
Points
50
40
30
Minimum Total
Points
41 points minimum
31 points minimum
1 point minimum
Initial Psychiatric SOAP Note Template
There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to develop your style of SOAP in the psychiatric practice setting.
Criteria
Clinical Notes
Informed
Consent
Informed
consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient
has the ability/capacity to respond and appears to
understand the risk, benefits, and (Will review additional
consent during treatment plan discussion)
Subjective
Verify Patient
Name:
DOB:
Minor:
Accompanied by:
Demographic:
Gender Identifier Note:
CC:
HPI:
Pertinent history in record and from patient: X
During assessment: Patient describes their mood as X and
indicated it has gotten worse in TIME.
Patient self-esteem appears fair, no reported feelings of excessive guilt,
no reported anhedonia, does not report sleep disturbance, does not report change in appetite, does not report libido disturbances, does not report change in
energy,
no reported changes in
concentration or memory.
Patient does not report increased activity, agitation,
risk-taking behaviors, pressured speech, or euphoria. Patient does not report excessive
fears, worries or panic attacks.
Patient does not report hallucinations, delusions,
obsessions or compulsions. Patient’s activity level, attention
and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or
gain. Patient does not report symptoms of a characterological nature.
SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent
behavior, denies
inappropriate/illegal behaviors.
Allergies: NKDFA.
(medication & food)
Past Medical Hx:
Medical
history: Denies
cardiac, respiratory, endocrine and neurological issues, including history
head injury.
Patient
denies history of
chronic infection, including MRSA, TB, HIV and Hep C.
Surgical history no surgical history reported
If
Minor obtain Developmental Hx: (most often from parents), in utero, birth and
delivery hx, early childhood, school hx, behavior, etc…
Nutritional status (this is an important
component to gauge how well the mind and body are being nourished for full
function. Ex: lack of iodine create thyroid issues, thyroid issues creates
metabolism issues which affects function of cognition, mood, etc…)
Past Psychiatric Hx:
Previous
psychiatric diagnoses: none reported.
Describes
stable course of illness.
Previous medication
trials: none reported.
Safety
concerns:
History of Violence to Self: none reported
History of Violence to Others: none
reported
Auditory
Hallucinations:
Visual
Hallucinations:
Mental
health treatment history discussed:
History of outpatient treatment: not reported
Previous psychiatric hospitalizations: not reported
Prior substance
abuse treatment: not
reported
Trauma history:
Client does not
report history of trauma including abuse, domestic violence, witnessing
disturbing events.
Substance Use:
Client denies use or
dependence on nicotine/tobacco products.
Client
does not report abuse
of or dependence on ETOH, and other illicit drugs.
Current Medications: No current medications.
(Contraceptives):
Supplements:
Past Psych Med Trials:
Family Medical Hx:
Family Psychiatric Hx:
Substance use
Suicides
Psychiatric diagnoses/hospitalization
Developmental diagnoses
Social History:
Occupational
History: currently unemployed.
Denies previous occupational hx
Military
service History: Denies previous military hx.
Education
history: completed
HS and vocational certificate
Developmental History: no significant
details reported.
(Childhood
History)
Legal History: no
reported/known legal issues, no reported/known
conservator or guardian.
Spiritual/Cultural
Considerations: none
reported.
ROS:
Constitutional: No report of fever or weight loss.
Eyes: No report of acute vision changes or eye pain.
ENT: No report of hearing changes or difficulty swallowing.
Cardiac: No report of chest pain, edema or orthopnea.
Respiratory: Denies dyspnea, cough or wheeze.
GI: No report of abdominal pain.
GU: No report of dysuria or hematuria.
Musculoskeletal: No report of joint pain or swelling.
Skin: No report of rash, lesion, abrasions.
Neurologic: No report of seizures, blackout, numbness or focal weakness. Endocrine:
No report of
polyuria or polydipsia.
Hematologic: No report of blood clots or easy bleeding.
Allergy: No report of hives or allergic reaction.
Reproductive: No report of significant issues. (females:
GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…)
Verify Patient: Name, Assigned identification number
(e.g., medical record number), Date of birth, Phone number, Social security
number, Address, Photo.
Include demographics, chief complaint,
subjective information from the patient, names and relations of others
present in the interview.
HPI:
, Past Medical and Psychiatric History,
Current Medications, Previous Psych Med
trials,
Allergies.
Social History, Family History.
Review of Systems (ROS) – if ROS is
negative, “ROS noncontributory,” or “ROS negative with the exception of…”
Objective
Vital Signs: Stable
Temp:
BP:
HR:
R:
O2:
Pain:
Ht:
Wt:
BMI:
BMI Range:
LABS:
Lab findings WNL
Tox screen: Negative
Alcohol: Negative
HCG: N/A
Physical
Exam:
MSE:
Patient
is cooperative and conversant,
appears without acute distress, and fully oriented x 4. Patient is dressed appropriately for age and
season. Psychomotor activity appears within normal.
Presents
with
appropriate
eye contact,
euthymic affect –
full,
even,
congruent with reported mood of “x”. Speech:
spontaneous,
normal rate,
appropriate volume/tone with
no problems expressing self.
TC:
no abnormal content elicited,
denies suicidal ideation and
denies
homicidal ideation. Process appears
linear,
coherent,
goal-directed.
Cognition appears grossly intact with
appropriate attention span & concentration and average fund of knowledge.
Judgment appears
fair . Insight appears
fair
The patient is able to articulate needs, is motivated
for compliance and adherence to medication regimen. Patient is willing and able to
participate with treatment, disposition, and discharge planning.
Diagnostic testing:
·
PHQ-9, psychiatric assessment
This is where the “facts” are
located.
Vitals,
**Physical Exam (if performed, will not be performed
every visit in every setting)
Include relevant labs, test results, and
Include MSE, risk assessment here, and psychiatric screening measure results.
Assessment
DSM5 Diagnosis: with ICD-10 codes
Dx:
–
Dx:
–
Dx: –
Patient
has the ability/capacity appears to
respond to psychiatric medications/psychotherapy and appears to
understand the need for medications/psychotherapy and
is willing to maintain adherent.
Reviewed potential risks & benefits,
Black Box warnings, and alternatives including declining treatment.
Include
your findings, diagnosis and differentials (DSM-5 and any other medical
diagnosis) along with ICD-10 codes, treatment options, and patient
input regarding treatment options (if possible), including obstacles to
treatment.
Informed
Consent Ability
Plan
Inpatient:
Psychiatric. Admits to X as per HPI.
Estimated stay 3-5 days
Patient is found to be
stable and
has control of behavior. Patient likely poses a
minimal risk to self and a
minimal risk to others
at this time.
Patient
denies abnormal perceptions
and
does not appear to be
responding to internal stimuli.
Pharmacologic interventions: including dosage,
route, and frequency and non-pharmacologic:
·
No changes to current medication, as listed in
chart, at this time
·
or…Zoloft is an excellent option for many
women who experience any menstrual cycle complaints. I usually start at 50 mg and move to 100
week 6-8. f/u within 2 weeks initially then every 6-8 weeks.
Psychotherapy referral for CBT
Education, including health promotion, maintenance,
and psychosocial needs
Importance of medication
Discussed current tobacco use. NRT
not indicated.
Safety planning
Discuss worsening sx and when to
contact office or report to ED
Referrals: endocrinologist
for diabetes
Follow-up, including return to clinic (RTC) with
time frame and reason and any labs that are needed for next visit 2 weeks
☒ > 50% time spent counseling/coordination of care.
Time
spent in Psychotherapy 18
minutes
Visit lasted 55 minutes
Billing
Codes for visit:
XX
XX
XX
____________________________________________
NAME,
TITLE
Date: Click here to enter a date. Time: X
Include
a specific plan, including medications & dosing & titration
considerations, lab work ordered, referrals to psychiatric and medical
providers, therapy recommendations, holistic options and complimentary
therapies, and rationale for your decisions. Include when you will want to
see the patient next. This comprehensive plan should relate directly to your
Assessment and include patient education.