Comprehensive Psychiatric Evaluation 1 Step 1: You will use the Graduate Comprehensive Psychiatric Evaluation Template Download Graduate Comprehensive Psychiatric Evaluation Templateto: 1.     Compose

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 

Chief Complaint
(Reason for seeking health care) – S

4 to >3 pts

Exemplary

Includes a direct quote from patient
about presenting problem.

3 to >2 pts

Distinguished

Includes a direct quote from patient
and other unrelated information.

2 to >0 pts

Developing

Includes information but information
is NOT a direct quote.

0 pts

Novice

Information is completely missing.

/ 4 pts

Demographics – S

2 pts

Exemplary

Begins with patient initials, age,
race, ethnicity, and gender (5 demographics).

1.5 pts

Distinguished

Begins with 4 of the 5 patient
demographics (patient initials, age, race, ethnicity, and gender).

1 pts

Developing

Begins with 3 or less patient
demographics (patient initials, age, race, ethnicity, and gender).

0 pts

Novice

Information is completely missing.

/ 2 pts

History of the Present
Illness (HPI) – S

5 to >3 pts

Exemplary

Includes the presenting problem and
the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration,
Character, Aggravating factors, Relieving factors, Timing, and Severity).

3 to >2 pts

Distinguished

Includes the presenting problem and
6 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration,
Character, Aggravating factors, Relieving factors, Timing, and Severity).

2 to >1 pts

Developing

Includes the presenting problem and
4 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration,
Character, Aggravating factors, Relieving factors, Timing, and Severity).

1 to >0 pts

Novice

The presenting problem is not
clearly stated and/or there are < 4 of the 8 dimensions of the problem
(OLD CARTS – Onset, Location, Duration, Character, Aggravating factors,
Relieving factors, Timing, and Severity).

/ 5 pts

Allergies – S

2 pts

Exemplary

Includes NKA (including = Drug,
Environmental, Food, Herbal, and/or Latex or if allergies are present
(reports for each severity of allergy AND description of allergy).

1.5 pts

Distinguished

If allergies are present, student
does not list each type of drug, environmental factor, herbal, food, latex
name and include severity of allergy OR description of the allergy.

1 pts

Developing

If allergies are present, student
only lists the type of allergy and omits the name of the allergy.

0 pts

Novice

Information is completely missing.

/ 2 pts

Review of Systems
(ROS) – S

5 to >3 pts

Exemplary

Includes a minimum of 3 assessments
for each body system, assesses at least 9 body systems directed to chief
complaint, AND uses the words “admits” and “denies.”

3 to >2 pts

Distinguished

Includes 3 or fewer assessments for
each body system, assesses 5-8 body systems directed to chief complaint, AND
uses the words “admits” and “denies.”

2 to >0 pts

Developing

Includes 3 or fewer assessments for
each body system, and assesses less than 5 body systems directed to chief
complaint, OR student does not use the words “admits” and “denies.”

0 pts

Novice

Information is completely missing.

/ 5 pts

Vital Signs – O

2 pts

Exemplary

Includes all 8 vital signs, (BP
(with patient position), HR, RR, temperature (with Fahrenheit or Celsius and
route of temperature collection), weight, height, BMI (or percentiles for
pediatric population) and pain).

1.5 pts

Distinguished

Includes at least 6 vital signs, (BP
(with patient position), HR, RR, temperature (with Fahrenheit or Celsius and
route of temperature collection), weight, height, BMI (or percentiles for
pediatric population) and pain).

1 pts

Developing

Includes at least 4 vital signs, (BP
(with patient position), HR, RR, temperature (with Fahrenheit or Celsius and
route of temperature collection), weight, height, BMI (or percentiles for
pediatric population) and pain).

0 pts

Novice

Information is completely missing.

/ 2 pts

Labs, Diagnostic Tests
and Screening Tools – O

3 pts

Exemplary

During the visit: Includes a list of
the labs, diagnostic tests or screening tools reviewed at the visit, values
of lab results or screening tools, and highlights abnormal values, OR
acknowledges no labs/diagnostic tests were reviewed.

2 pts

Distinguished

During the visit: Includes a list of
the labs, diagnostic tests, or screening tools reviewed at the visit, but
does not include the values of lab results or screening tools, but does not
highlight abnormal values.

1 pts

Developing

During the visit: Includes a list of
the labs, diagnostic tests, or screening tools reviewed at the visit but does
not include the values of the results or highlight abnormal values.

0 pts

Novice

Information is completely missing.

/ 3 pts

Medications-S

3 pts

Exemplary

Includes a list of all of the
patient reported psychiatric and medical medications and the diagnosis for
the medication (including name, dose, route, frequency).

2 pts

Distinguished

Includes a list of all of the
patient reported psychiatric and but omits the medical medications and the
diagnosis for the medication (including name, dose, route, frequency).

1 pts

Developing

Includes a list of some of the
patient reported psychiatric and/or medical medications and the diagnosis for
the medication (omits the dose, route, frequency of the medications).

0 pts

Novice

Information is completely missing.

/ 3 pts

Past Medical History-S

3 pts

Exemplary

Includes (Major/Chronic, Trauma,
Hospitalizations), for each medical diagnosis, year of diagnosis and whether
the diagnosis is active or current.

2 pts

Distinguished

Includes (Major/Chronic, Trauma,
Hospitalizations), for each medical diagnosis, either year of diagnosis OR
whether the diagnosis is active or current.

1 pts

Developing

Includes each medical diagnosis but
does not include year of diagnosis or whether the diagnosis is active or
current.

0 pts

Novice

Information is completely missing.

/ 3 pts

Past Psychiatric
History-S

4 to >3 pts

Exemplary

Includes (Outpatient and
Hospitalizations), for each psychiatric diagnosis (including addiction
treatment), and year of diagnosis.

3 to >2 pts

Distinguished

Includes (Outpatient and
Hospitalizations), for each psychiatric diagnosis (omits addiction treatment),
and year of diagnosis.

2 to >0 pts

Developing

Includes (Outpatient and
Hospitalizations), for each psychiatric diagnosis (including addiction
treatment), and does not include the year of diagnosis.

0 pts

Novice

The information is completely missing.

/ 4 pts

Family Psychiatric
History-S

4 to >3 pts

Exemplary

Includes an assessment of at least 6
family members regarding, at a minimum, genetic disorders, mood disorder,
bipolar disorder, and history of suicidal attempts.

3 to >2 pts

Distinguished

Includes an assessment of at least 4
family members regarding, at a minimum, genetic disorders, mood disorder,
bipolar disorder, and history of suicidal attempts.

2 to >0 pts

Developing

Includes an assessment of at least 2
family members regarding, at a minimum, genetic disorders, mood disorder,
bipolar disorder, and history of suicidal attempts.

0 pts

Novice

Information is completely missing.

/ 4 pts

Social History-S

3 pts

Exemplary

Distinguished Includes all 11 of the
following: tobacco use, drug use, alcohol use, marital status, employment
status, current and previous occupation, sexual orientation, sexually active,
contraceptive use/pregnancy status, and living situation.

2 pts

Distinguished

Includes at least 8 of the
following: tobacco use, drug use, alcohol use, marital status, employment
status, current and previous occupation, sexual orientation, sexually active,
contraceptive use/pregnancy status, and living situation.

1 pts

Developing

Includes all 6 of the following:
tobacco use, drug use, alcohol use, marital status, employment status,
current and previous occupation, sexual orientation, sexually active,
contraceptive use/pregnancy status, and living situation.

0 pts

Novice

Information is completely missing.

/ 3 pts

Mental Status Exam-O

15 to >12 pts

Exemplary

Includes all 10 components of the
mental status exam (appearance, attitude/behavior, mood, affect, speech,
thought process, thought content/ perception, cognition, insight and
judgement) with detailed descriptions for each area.

12 to >10 pts

Distinguished

Includes all 8 components of the
mental status exam (appearance, attitude/behavior, mood, affect, speech,
thought process, thought content/ perception, cognition, insight and
judgement) with detailed descriptions for each area.

10 to >0 pts

Developing

Includes >6 components of the
mental status exam (appearance, attitude/behavior, mood, affect, speech,
thought process, thought content/ perception, cognition, insight and
judgement) with some descriptions for each area.

0 pts

Novice

Includes <3 components of the
mental status exam (appearance, attitude/behavior, mood, affect, speech,
thought process, thought content/ perception, cognition, insight and
judgement) OR detailed descriptions is not included for each area.

/ 15 pts

Primary Diagnoses-A

11 to >6 pts

Exemplary

Includes a clear outline of the
accurate principal diagnosis AND lists the remaining diagnoses addressed at
the visit (in descending priority) using the DSM-5-TR. The correct ICD-10
billing code is used.

6 to >3 pts

Distinguished

Includes a clear outline of the
accurate diagnoses addressed at the visit but does not list the diagnoses in
descending order of priority using the DSM-5-TR. The correct ICD-10 billing
code is used.

3 to >0 pts

Developing

Includes an inaccurate diagnosis as
the principal diagnosis. The ICD-10 code is incorrect or missing.

0 pts

Novice

Information is completely missing.

/ 11 pts

Differential
Diagnoses-A

3 pts

Exemplary

Includes at least 2 differential
diagnoses that can be supported by the subjective and objective data provided
using the DSM-5-TR. The correct ICD-10 billing code is used.

2 pts

Distinguished

Includes 1 differential diagnosis
that can be supported by the subjective and objective data provided using the
DSM-5-TR. The correct ICD-10 billing code is used.

1 pts

Developing

Includes at least 1 differential
diagnosis that is NOT supported by the subjective and objective data. The
ICD-10 code is incorrect or missing.

0 pts

Novice

Information is completely missing.

/ 3 pts

Outcome Labs/Screening
Tools – O

3 pts

Exemplary

After the visit: orders appropriate
diagnostic/lab testing or screening tool 100% of the time OR acknowledges “no
diagnostic testing or screening tool clinically required at this time.”

2 pts

Distinguished

After the visit: orders appropriate
diagnostic/lab testing 50% of the time OR acknowledges “no diagnostic testing
or screening tool clinically required at this time.”

1 pts

Developing

After the visit, orders appropriate
diagnostic testing less than 50% of the time.

0 pts

Novice

Information is completely missing.

/ 3 pts

Treatment

10 to >8 pts

Exemplary

Includes a detailed pharmacologic
and non pharmacological treatment plan for each of the diagnoses listed under
“assessment”. The plan includes ALL of the following: drug/vitamin/herbal
name, dose, route, frequency, duration and cost as well as education related
to pharmacologic agent. For non-pharmacological treatment, includes:
treatment name, frequency, duration. If the diagnosis is a chronic problem,
student includes instructions on currently prescribed medications as above.
The plan is supported by the current US clinical guidelines.

8 to >6 pts

Distinguished

Includes a detailed pharmacologic
and non pharmacological treatment plan for each of the diagnoses listed under
“assessment”. The plan includes 4-7 of the following: drug/vitamin/herbal
name, dose, route, frequency, duration and cost as well as education related
to pharmacologic agent. For non-pharmacological treatment, includes:
treatment name, frequency, duration. If the diagnosis is a chronic problem,
student includes instructions on currently prescribed medications as above.
The plan is supported by the current US clinical guidelines.

6 to >0 pts

Developing

Includes a detailed pharmacologic
and non pharmacological treatment plan for each of the diagnoses listed under
“assessment”. The plan includes 4 of the following: drug/vitamin/herbal name,
dose, route, frequency, duration and cost as well as education related to
pharmacologic agent. Non-pharmacological treatment NOT included. If the
diagnosis is a chronic problem, student includes instructions on currently
prescribed medications as above. The plan is NOT supported by the current US
clinical guidelines OR is unsafe.

0 pts

Novice

Information is completely missing.

/ 10 pts

Patient/Family
Education-P

5 to >3 pts

Exemplary

Includes at least 3 strategies to
promote and develop skills for managing their illness and at least 3
self-management methods on how to incorporate healthy behaviors into their
lives.

3 to >2 pts

Distinguished

Includes at least 2 strategies to
promote and develop skills for managing their illness and at least 2
self-management methods on how to incorporate healthy behaviors into their
lives.

2 to >0 pts

Developing

Includes at least 1 strategies to
promote and develop skills for managing their illness and at least 1
self-management methods on how to incorporate healthy behaviors into their
lives.

0 pts

Novice

Information is completely missing.

/ 5 pts

Referral

3 pts

Exemplary

Provides a detailed list of medical
and other interdisciplinary referrals or documents NO REFERRAL ADVISED AT
THIS TIME. Includes a timeline for follow up appointments.

2 pts

Distinguished

Provides a medical or other
interdisciplinary referral or documents NO REFERRAL ADVISED AT THIS TIME.
Includes a timeline for follow up appointments.

1 pts

Developing

Provides a medical or other
interdisciplinary referral. DOES NOT include a timeline for follow up
appointments.

0 pts

Novice

Information is completely missing.

/ 3 pts

APA Formatting

5 to >3 pts

Exemplary

Effectively uses literature and
other resources to inform their work. Exceptional use of citations and
extended referencing. High level of precision with APA 7th Edition writing
style.

3 to >2 pts

Distinguished

Effectively uses literature and
other resources to inform their work. Moderate use of citations and extended
referencing. Moderate level of precision with APA 7th Edition writing style.

2 to >0 pts

Developing

Ineffectively uses literature and
other resources to inform their work. Moderate use of citations and extended
referencing. APA 7th Edition writing style not strictly adhered to.

0 pts

Novice

APA style and writing mechanics not
used.

/ 5 pts

References

5 to >3 pts

Exemplary

The reference page contains at least
the required current scholarly academic reference and text reference. Follows
APA guidelines of components: double space, 12 pt. font, abstract, level
headings, hanging indent and in-text citations.

3 to >2 pts

Distinguished

References page contains one current
scholarly academic resource and text reference. Follows most APA guidelines
of components: double space, 12 pt. font, abstract, level headings, hanging
indent, and in-text citations.

2 to >0 pts

Developing

References page contains one current
or outdated scholarly academic resource. Many errors of APA guidelines:
double space, 12 pt. font, abstract, level headings, hanging indent, and
in-text citations.

0 pts

Novice

References page contains no current
scholarly academic resources, only internet webpages or no reference page.
Lack of APA guidelines for references provided or in-text citations.

/ 5 pts