Comprehensive psychiatric assessment interview of an adult/older adult
In this assignment, you will complete a comprehensive psychiatric assessment interview of an adult/older adult. You can use a patient you’ve seen in clinical or someone in your personal life. Your assessment should be comprehensive, and you should refer to course texts to inform items for inclusion in your assessment. Keep in mind that you will be responsible for covering those areas addressed in the reading assignments up to this point.
Initial Psychiatric Interview/SOAP Note Template
There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to develop your style of SOAP in the psychiatric practice setting.
Criteria Clinical Notes
Informed Consent Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient the ability/capacity to respond and appears to the risk, benefits, and (Will review additional consent during treatment plan discussion)
Subjective Verify Patient
Name:
DOB:
Minor:
Accompanied by:
Demographic:
Gender Identifier Note:
CC:
HPI:
Pertinent history in record and from patient: X
During assessment: Patient describes their mood .
Patient self-esteem appears , ,
, , , , ,
.
Patient . Patient .
Patient . Patient’s . Patient symptoms of eating disorder. There is . Patient symptoms of a characterological nature.
SI/ HI/ AV: Patient currently suicidal ideation, SIBx, homicidal ideation, violent behavior, inappropriate/illegal behaviors.
Allergies: .
(medication & food)
Past Medical Hx:
Medical history:
Patient .
Surgical history
Past Psychiatric Hx:
Previous psychiatric diagnoses: .
Describes course of illness.
Previous medication trials: .
Safety concerns:
History of Violence to Self:
History of Violence to Others:
Auditory Hallucinations:
Visual Hallucinations:
Mental health treatment history discussed:
History of outpatient treatment:
Previous psychiatric hospitalizations:
Prior substance abuse treatment:
Trauma history: Client
Substance Use: Client
Client
Current Medications: .
(Contraceptives):
Supplements:
Past Psych Med Trials:
Family Medical Hx:
Family Psychiatric Hx:
Substance use
Suicides
Psychiatric diagnoses/hospitalization
Developmental diagnoses
Social History:
Occupational History: currently .
Military service History: Denies previous military hx.
Education history: completed HS and vocational certificate
Developmental History:
(Childhood History include in utero if available)
Legal History: , .
Spiritual/Cultural Considerations: .
ROS:
Constitutional: .
Eyes: .
ENT:
Cardiac: .
Respiratory: .
GI: .
GU.
Musculoskeletal:
Skin.
Neurologic: . Endocrine: .
Hematologic:
Allergy:
Reproductive: . (females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…)
Verify Patient: Name, Assigned identification number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo.
Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview.
HPI:
, Past Medical and Psychiatric History,
Current Medications, Previous Psych Med trials,
Allergies.
Social History, Family History.
Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…”
Objective Vital Signs:
Temp:
BP:
HR:
R:
O2:
Pain:
Ht:
Wt:
BMI:
BMI Range:
LABS:
Lab findings
Tox screen:
Alcohol:
HCG:
Physical Exam:
MSE:
Patient is cooperative and conversant, appears without acute distress, and fully oriented x 4. Patient is dressed . Psychomotor activity appears .
Presents with eye contact, affect – , , with reported mood of “x”. Speech: , rate, volume/tone with .
TC: content elicited, suicidal ideation and homicidal ideation. Process appears , , .
Cognition with attention span & concentration and average fund of knowledge.
Judgment appears . Insight appears
The patient to articulate needs, motivated for compliance and adherence to medication regimen. Patient is willing and able to participate with treatment, disposition, and discharge planning.
This is where the “facts” are located.
Vitals,
**Physical Exam (if performed, will not be performed every visit in every setting)
Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results.
Assessment DSM5 Diagnosis: with ICD-10 codes
Dx:
Dx:
Dx:
Patient the ability/capacity appears to respond to psychiatric medications/psychotherapy and appears to the need for medications/psychotherapy and willing to maintain adherent.
Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment.
Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment.
Informed Consent Ability
Plan
(Note some items may only be applicable in the inpatient environment)
Inpatient:
Psychiatric. as per HPI.
Estimated stay days
Safety Risk/Plan: Patient is found to be and of behavior. Patient likely poses a risk to self and a risk to others at this time.
Patient abnormal perceptions and appear to be responding to internal stimuli.
Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic:
or…Zoloft is an excellent option for many women who experience any menstrual cycle complaints. I usually start at 50 mg and move to 100 week 6-8. f/u within 2 weeks initially then every 6-8 weeks.
Psychotherapy referral for CBT
Education, including health promotion, maintenance, and psychosocial needs
Importance of medication
Discussed current tobacco use. NRT indicated.
Safety planning
Discuss worsening sx and when to contact office or report to ED
Referrals: endocrinologist for diabetes
Follow-up, including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit 2 weeks
50% time spent counseling/coordination of care.
Time spent in Psychotherapy minutes
Visit lasted minutes
Billing Codes for visit:
XX
XX
XX
Date: Time: