Week 4 comprehensive psychotherapy evaluation 2

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  1. Compose a written comprehensive psychiatric eval of an adult patient you have seen in the clinic . Please use the template attached. Do not use “within normal limits”. “admits or denies” Is accepted. FOLLOW THE RUBRIC BELOW.

PLEASE FOLLOW REQUIREMENTS:formatted and cited in current APA style 7 ed  with support from at least 5 academic sources which need to be journal articles or books from 2019 up to now. NO WEBSITES allowed for reference entry. Include doi, page numbers, etc. Plagiarism must be less than 10%. RUBRIC : Chief Complaint :  Reason for seeking health. Includes a direct quote from patient about presenting problem .Demographics : Begins with patient initials, age, race, ethnicity, and gender (5 demographics).  History of the Present Illness (HPI) – Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors,Timing, and Severity). Allergies –  Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy).  Review of Systems (ROS) – 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.”   Vital Signs – 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).  Labs, Diagnostic, PERFORMED. During the visit: Includes a list of the labs, diagnostic or screening tools reviewed at the visit, values of lab results or screening tools, and highlights abnormal values, OR acknowledges no labs/diagnostic  were reviewed.  Medications- Includes a list of all of the patient reported psychiatric and medical medications and the diagnosis for the medication (including name, dose, route, frequency).  Past Medical History- Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active orcurrent.  Past Psychiatric History- Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including ADDICTION treatment and date of the diagnosis) Family Psychiatric History- Includes an assessment of at least 6 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder, and history of suicidal attempts.  Social History- Includes all 11 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation.  Mental Status – Includes all 10 components of the mental status section (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/perception, cognition, insight and judgement) with detailed descriptions for each area. 

PSYCHOTHERAPY NOTE: IT NEEDS TO BE WELL DEVELOPED AND ACCURATE.

 

LABS (values included) performed to rule out any  medical conditionPrimary Diagnoses- Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)using the DSM-5-TR. The correct ICD-10 billing code is used. DSM-5-TR. The correct ICD-10 billing code is used.  Differential Diagnoses: Includes at least 2 differential diagnoses that can be supported by the subjective and objective data provided using the DSM-5-TR. The correct ICD-10 billing code is used.  Outcome Labs/Screening Tools –  After the visit: orders appropriate diagnostic/lab or screening tool 100% of the time OR acknowledges “no diagnostic  or screening tool clinically required at this time.”  Treatment 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. The plan is supported by the cufrent US guidelines.   Patient/Family Education- 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.  Referral : Provides a detailedlist of medical and interdisciplinary referrals  or NO REFERRAL ADVISED AT THIS TIME. Includes a timeline for follow up appointments.  APA Formatting : Effectively uses literature and other resource. Exceptional use of citations and extended referencing. High level of precision with APA 7th Edition writing style.  References: The references contains at least 5 current scholarly academic reference and in-literature citations reference. Follows APA guidelines of components: double space, 12 pt. font, abstract, level headings, hanging indent.  

Comprehensive Psychiatric Evaluation Template

With Psychotherapy Note

Encounter date: ________________________

Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____

Reason for Seeking Health Care: ______________________________________________

HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SI/HI: _______________________________________________________________________________

Sleep:  _________________________________________        
Appetite:  ________________________

Allergies (Drug/Food/Latex/Environmental/Herbal): ___________________________________

Current perception of Health: Excellent Good Fair Poor

Psychiatric History:


Inpatient hospitalizations:


Date


Hospital


Diagnoses


Length of Stay


Outpatient psychiatric treatment:


Date


Hospital


Diagnoses


Length of Stay


Detox/Inpatient substance treatment:


Date


Hospital


Diagnoses


Length of Stay


History of suicide attempts and/or self injurious behaviors:
____________________________________

Past Medical History

· Major/Chronic Illnesses____________________________________________________

· Trauma/Injury ___________________________________________________________

· Hospitalizations __________________________________________________________

Past Surgical History___________________________________________________________


Current psychotropic medications:
 

_________________________________________ ________________________________

_________________________________________ ________________________________

_________________________________________ ________________________________


Current prescription medications:
 

_________________________________________ ________________________________

_________________________________________ ________________________________

_________________________________________ ________________________________


OTC/Nutritionals/Herbal/Complementary therapy:

_________________________________________ ________________________________

_________________________________________ ________________________________


Substance use

: (alcohol, marijuana, cocaine, caffeine, cigarettes)


Substance


Amount


Frequency


Length of Use

Family Psychiatric History: _____________________________________________________

Social History

Lives: Single family House/Condo/ with stairs: ___________
Marital Status:________

Education:____________________________

Employment Status: ______
Current/Previous occupation type: _________________

Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________

Sexual Orientation: _______ Sexual Activity: ____
Contraception Use: ____________

Family Composition: Family/Mother/Father/Alone
: _____________________________

Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________

________________________________________________________________________

Health Maintenance

Screening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, Dementia

Exposures:

Immunization HX:

Review of Systems (at least 3 areas per system):

General:

HEENT:

Neck:

Lungs:

Cardiovascular:

Breast:

GI:

Male/female genital:

GU:

Neuro:

Musculoskeletal:

Activity & Exercise:

Psychosocial:

Derm:

Nutrition:

Sleep/Rest:

LMP:

STI Hx:

Physical Exam

BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
percentile) _____

General:

HEENT:

Neck:

Pulmonary:

Cardiovascular:

Breast:

GI:

Male/female genital:

GU:

Neuro:

Musculoskeletal:

Derm:

Psychosocial:

Misc.

Mental Status Exam

Appearance:

Behavior:

Speech:

Mood:

Affect:

Thought Content:

Thought Process:

Cognition/Intelligence:

Clinical Insight:

Clinical Judgment:

Psychotherapy Note

Therapeutic Technique Used:

Session Focus and Theme:

Intervention Strategies Implemented:

Evidence of Patient Response:

Plan:

Differential Diagnoses

1.

2.

Principal Diagnoses

1.

2.

Plan:

Diagnosis #1

Diagnostic Testing/Screening:

Pharmacological Treatment:

Non-Pharmacological Treatment:

Patient/Family Education:

Referrals:

Follow-up:

Anticipatory Guidance:

Diagnosis #2

Diagnostic Testing/Screening Tool:

Pharmacological Treatment:

Non-Pharmacological Treatment:

Patient/Family Education:

Referrals:

Follow-up:

Anticipatory Guidance:

Signature (with appropriate credentials): __________________________________________

Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________

DEA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)______________________________ Age ___________

Date: _______________

RX ______________________________________

SIG:

Dispense: ___________
Refill: _________________

No Substitution

Signature: ____________________________________________________________

Rev. 2272022 LM

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