this soap note will be on a patient you made up who has schizophernia  Step 1: You will use the 

this soap note will be on a patient you made up who has schizophernia 

Step 1: You will use the 

Graduate Comprehensive Psychiatric Evaluation Template


 Download Graduate Comprehensive Psychiatric Evaluation Template
to:

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

2. 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 

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 


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