- Compose a written comprehensive psychiatric and/or psychotherapy evaluation of a patient you have seen in the clinic.
- Upload your completed comprehensive psychiatric and/or psychotherapy evaluation as a Word doc.
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.
|
S = |
Subjective data: Patients 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 Reminder: It is important that you complete this assessment using your critical thinking skills. You are expected to synthesize your clinical assessment, formulate a psychiatric diagnosis, and develop a treatment plan independently. It is not acceptable to document “my preceptor made this diagnosis.” It is not acceptable to document within normal limits. |
Requirements: N/A
Get this or a similar paper done in as fast as 4 hours, 24/7.
NB: We do not sell prewritten papers. All essays are written from scratch according to specific needs and instructions
Leave a Reply
You must be logged in to post a comment.