STU Social Phobia Patient Comprehensive Psychiatric Evaluation – Description
Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.
Upload your completed comprehensive psychiatric evaluation as a Word doc. Scanned PDFs will not be accepted.
For the Comprehensive Psychiatric Evaluation Presentation Assignment: You will need to get it signed by your preceptor for the presentation (actual signature, not electronically typed) Β SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. Β S = Subjective data: Patientβs 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) O = Objective data: Medications; Allergies; Past medical history; Family psychiatric 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 Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up
Reminder: It is important that you complete this assessment using your critical thinking skills. Β 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.” Β An example of the appropriate descriptors of the clinical evaluation is listed below. Β It is not acceptable to document βwithin normal limits.β
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