23 Mar Comprehensive Psychiatric and Psychotherapy Evaluation

Step 1: You will use the Graduate Comprehensive Psychiatric/ Psychotherapy Evaluation Template

Download Graduate Comprehensive Psychiatric/Psychotherapy Evaluation Template to:

1. Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.

2. Upload your completed comprehensive psychiatric evaluation as a Word doc. Scanned PDFs will not be accepted. • For the Comprehensive Evaluation Presentation

Assignment: You will need to get it signed by your preceptor for the presentation (actual signature, not electronically typed).

Step 2: Each student will create a focused SOAP note video presentation in the next assignment. See Comprehensive Evaluation Presentation 1 for more details.

SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.

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)

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

https://stu.instructure.com/courses/50352/files/4924029?wrap=1
https://stu.instructure.com/courses/50352/files/4924029?wrap=1
https://stu.instructure.com/courses/50352/files/4924029?wrap=1
https://stu.instructure.com/courses/50352/files/4924029/download?download_frd=1
https://stu.instructure.com/courses/50352/files/4924029/download?download_frd=1
https://stu.instructure.com/courses/50352/files/4924029/download?download_frd=1
https://stu.instructure.com/courses/50352/assignments/747635?wrap=1

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 evaluation.

• 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.”

Patient PTSD with Comorbid Depression

1. CPT Code/Time: 90791 (Psychiatric diagnostic evaluation, 30 min) ICD-10 Code: F43.12 – PTSD, chronic; F32.1 – Major Depressive Disorder, moderate

2. Gender: Male

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

https://www.nccih.nih.gov/health/providers/clinicalpractice
https://www.nccih.nih.gov/health/providers/clinicalpractice
https://www.nccih.nih.gov/health/providers/clinicalpractice
https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines
https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines
https://www.jaacap.org/article/S0890-8567(09)62592-2/fulltext
https://www.jaacap.org/article/S0890-8567(09)62592-2/fulltext
https://www.jaacap.org/article/S0890-8567(09)62591-0/fulltext
https://www.jaacap.org/article/S0890-8567(09)62591-0/fulltext

3. Insurance: Medicare

4. Ethnicity: Hispanic (Mexican American)

5. Chief Complaint: “I feel empty all the time and can’t stop thinking about the accident.”

6. Explanatory Note: Older adult with PTSD symptoms after a car accident 2 years ago, complicated by persistent low mood.

7. Race: Hispanic

8. Age: 67

9. Reason for Visit: New consult

10. Social Problems Addressed: Emotional distress, social isolation, loss of independence after accident

11. Immunizations: Missing shingles vaccine

12. Procedures/Evaluation: PCL-5 = 48; PHQ-9 = 17. MSE: depressed mood, restricted affect, intact thought process.

13. Principal Diagnosis: PTSD, chronic – F43.12; MDD, moderate – F32.1

14. Differentials:

• F41.1 – GAD (anxiety broad, not trauma-specific)

• F33.1 – MDD, recurrent, moderate (PTSD symptoms primary driver)

• F43.21 – Adjustment Disorder with Anxiety (symptoms persistent beyond 6 months)

15. Treatment: Venlafaxine XR 75 mg PO daily × 30 days, #30, 1 refill.

16. Medication Education: Venlafaxine effective for PTSD and depression. Discussed risk of hypertension, GI upset, insomnia. Warned about withdrawal with abrupt discontinuation.

17. Non-Pharmacological: CBT for trauma, supportive psychotherapy for depression.

18. Referrals: Physical therapy for mobility, community senior center for socialization.

19. Follow-up: 6 weeks for mood and trauma symptom response.

20. Vitals: BP 148/88, Temp 98.4°F, HR 82, RR 18, Ht 5’7”, Wt 195 lb, BMI 30.5 (obese)

21. HPI: Patient is a 67-year-old Mexican American male presenting with chronic intrusive thoughts, nightmares, and avoidance behaviors since a car accident 2 years ago that left

him with mobility limitations. He reports persistent sadness, guilt about the accident, irritability, and reduced interest in hobbies. He lives alone and rarely sees friends. He denies hallucinations or suicidal intent. He reports trouble sleeping and fatigue most days. He seeks help because symptoms interfere with daily functioning and independence.