Comprehensive Psychotherapy Evaluation 2
Step 1: You will use the Graduate Comprehensive Psychotherapy Evaluation Template to:
Compose a written comprehensive psychotherapy evaluation of a patient you have seen in the clinic.
Upload your completed comprehensive psychiatric evaluation as a Word doc. Scanned PDFs will not be accepted.
For the Comprehensive Psychotherapy 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 Psychotherapy Evaluation Presentation 2 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 
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