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 


Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

Module 6 Discussion   Personhood Discuss the concept of

Module 6 Discussion   Personhood Discuss the concept of personhood as used in the nursing as caring theory. Submission Instructions: · Your initial post must be at least 500 words, formatted, and cited in current APA style with support from at least two academic sources. · Quotes “……” cannot be

Module 6 Discussion   Treatments for  Genitourinary Tract Disorders

Module 6 Discussion   Treatments for  Genitourinary Tract Disorders Based on  Module 6: Lecture Materials & Resources and experience, please answer the following questions: 1. Describe urinary tract infection, causes, symptoms and treatment 2. Discuss treatment for benign prostatic hyperplasia 3. Describe overactive bladder, causes, symptoms and treatment  4. Treatment options

adult with a primary diagnosis of generalized anxiety disorder Comprehensive Psychiatric Evaluation Template

adult with a primary diagnosis of generalized anxiety disorder 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):