Assignment Prompt & Instructions
**files (4)**
– ## NUR650CLCPEInstructionsW2.pdf
– GraduateComprehensivePsychiatricEvaluationandPsychotherapyNoteTemplaterev.3112022.docx
– NUR640CLCPEwk4-2.docx
– PsychiatricSOAPNoteRubric1.docx
**## NUR650CLCPEInstructionsW2.pdf**
Comprehensive Psychiatric and
Psychotherapy Evaluation 1
Step 1: You will use the Graduate Comprehensive Psychiatric/
Psychotherapy Evaluation Template
Download Graduate Comprehensive Psychiatric/Psychotherapy
Evaluation Template
to:
1. Compose a written comprehensive psychiatric evaluation of
a patient you have seen in the clinic.
2. Upload your completed comprehensive psychiatric
evaluation as a Word doc. Scanned PDFs will not be
accepted.
• For the Comprehensive 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 Evaluation Presentation 1 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
[https://stu.instructure.com/courses/50352/files/4924029?wrap=1](https://stu.instructure.com/courses/50352/files/4924029?wrap=1)
[https://stu.instructure.com/courses/50352/files/4924029?wrap=1](https://stu.instructure.com/courses/50352/files/4924029?wrap=1)
[https://stu.instructure.com/courses/50352/files/4924029?wrap=1](https://stu.instructure.com/courses/50352/files/4924029?wrap=1)
[https://stu.instructure.com/courses/50352/files/4924029/download?download_frd=1](https://stu.instructure.com/courses/50352/files/4924029/download?download_frd=1)
[https://stu.instructure.com/courses/50352/files/4924029/download?download_frd=1](https://stu.instructure.com/courses/50352/files/4924029/download?download_frd=1)
[https://stu.instructure.com/courses/50352/files/4924029/download?download_frd=1](https://stu.instructure.com/courses/50352/files/4924029/download?download_frd=1)
[https://stu.instructure.com/courses/50352/assignments/747635?wrap=1](https://stu.instructure.com/courses/50352/assignments/747635?wrap=1)
Other: Incorporate current clinical guidelines NIH Clinical
Guidelines
Links to an external site.
or APA Clinical Guidelines
Links to an external site.
, research articles, and the role of the PMHNP in your
evaluation.
• Psychiatric Assessment of Infants and ToddlersLinks to an
external site.
• Psychiatric Assessment of Children and AdolescentsLinks
to an external site.
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." An example of
the appropriate descriptors of the clinical evaluation is listed
below. It is not acceptable to document “within normal limits.”
Patient PTSD with Comorbid Depression
1. CPT Code/Time: 90791 (Psychiatric diagnostic evaluation, 30 min)
ICD-10 Code: F43.12 – PTSD, chronic; F32.1 – Major Depressive Disorder, moderate
2. Gender: Male
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
[https://www.nccih.nih.gov/health/providers/clinicalpractice](https://www.nccih.nih.gov/health/providers/clinicalpractice)
[https://www.nccih.nih.gov/health/providers/clinicalpractice](https://www.nccih.nih.gov/health/providers/clinicalpractice)
[https://www.nccih.nih.gov/health/providers/clinicalpractice](https://www.nccih.nih.gov/health/providers/clinicalpractice)
[https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines](https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines)
[https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines](https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines)
[https://www.jaacap.org/article/S0890-8567(09)62592-2/fulltext](https://www.jaacap.org/article/S0890-8567(09)62592-2/fulltext)
[https://www.jaacap.org/article/S0890-8567(09)62592-2/fulltext](https://www.jaacap.org/article/S0890-8567(09)62592-2/fulltext)
[https://www.jaacap.org/article/S0890-8567(09)62591-0/fulltext](https://www.jaacap.org/article/S0890-8567(09)62591-0/fulltext)
[https://www.jaacap.org/article/S0890-8567(09)62591-0/fulltext](https://www.jaacap.org/article/S0890-8567(09)62591-0/fulltext)
3. Insurance: Medicare
4. Ethnicity: Hispanic (Mexican American)
5. Chief Complaint: “I feel empty all the time and can’t stop thinking about the accident.”
6. Explanatory Note: Older adult with PTSD symptoms after a car accident 2 years ago,
complicated by persistent low mood.
7. Race: Hispanic
8. Age: 67
9. Reason for Visit: New consult
10. Social Problems Addressed: Emotional distress, social isolation, loss of independence
after accident
11. Immunizations: Missing shingles vaccine
12. Procedures/Evaluation: PCL-5 = 48; PHQ-9 = 17. MSE: depressed mood, restricted
affect, intact thought process.
13. Principal Diagnosis: PTSD, chronic – F43.12; MDD, moderate – F32.1
14. Differentials:
• F41.1 – GAD (anxiety broad, not trauma-specific)
• F33.1 – MDD, recurrent, moderate (PTSD symptoms primary driver)
• F43.21 – Adjustment Disorder with Anxiety (symptoms persistent beyond 6 months)
15. Treatment: Venlafaxine XR 75 mg PO daily × 30 days, #30, 1 refill.
16. Medication Education: Venlafaxine effective for PTSD and depression. Discussed risk
of hypertension, GI upset, insomnia. Warned about withdrawal with abrupt
discontinuation.
17. Non-Pharmacological: CBT for trauma, supportive psychotherapy for depression.
18. Referrals: Physical therapy for mobility, community senior center for socialization.
19. Follow-up: 6 weeks for mood and trauma symptom response.
20. Vitals: BP 148/88, Temp 98.4°F, HR 82, RR 18, Ht 5’7”, Wt 195 lb, BMI 30.5 (obese)
21. HPI: Patient is a 67-year-old Mexican American male presenting with chronic intrusive
thoughts, nightmares, and avoidance behaviors since a car accident 2 years ago that left
him with mobility limitations. He reports persistent sadness, guilt about the accident,
irritability, and reduced interest in hobbies. He lives alone and rarely sees friends. He
denies hallucinations or suicidal intent. He reports trouble sleeping and fatigue most days.
He seeks help because symptoms interfere with daily functioning and independence.
22. Allergies: NKDA
**GraduateComprehensivePsychiatricEvaluationandPsychotherapyNoteTemplaterev.3112022.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/graduatecomprehensivepsychiatricevaluationandpsychotherapynotetemplaterev-3112022-docx-10519163)
**NUR640CLCPEwk4-2.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/nur640clcpewk4-2-docx)
**PsychiatricSOAPNoteRubric1.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/psychiatricsoapnoterubric1-docx-10519165)
**PsychiatricSOAPNoteRubric1.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/psychiatricsoapnoterubric1-docx-10519165)
**## NUR650CLCPEInstructionsW2.pdf**
Comprehensive Psychiatric and
Psychotherapy Evaluation 1
Step 1: You will use the Graduate Comprehensive Psychiatric/
Psychotherapy Evaluation Template
Download Graduate Comprehensive Psychiatric/Psychotherapy
Evaluation Template
to:
1. Compose a written comprehensive psychiatric evaluation of
a patient you have seen in the clinic.
2. Upload your completed comprehensive psychiatric
evaluation as a Word doc. Scanned PDFs will not be
accepted.
• For the Comprehensive 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 Evaluation Presentation 1 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
[https://stu.instructure.com/courses/50352/files/4924029?wrap=1](https://stu.instructure.com/courses/50352/files/4924029?wrap=1)
[https://stu.instructure.com/courses/50352/files/4924029?wrap=1](https://stu.instructure.com/courses/50352/files/4924029?wrap=1)
[https://stu.instructure.com/courses/50352/files/4924029?wrap=1](https://stu.instructure.com/courses/50352/files/4924029?wrap=1)
[https://stu.instructure.com/courses/50352/files/4924029/download?download_frd=1](https://stu.instructure.com/courses/50352/files/4924029/download?download_frd=1)
[https://stu.instructure.com/courses/50352/files/4924029/download?download_frd=1](https://stu.instructure.com/courses/50352/files/4924029/download?download_frd=1)
[https://stu.instructure.com/courses/50352/files/4924029/download?download_frd=1](https://stu.instructure.com/courses/50352/files/4924029/download?download_frd=1)
[https://stu.instructure.com/courses/50352/assignments/747635?wrap=1](https://stu.instructure.com/courses/50352/assignments/747635?wrap=1)
Other: Incorporate current clinical guidelines NIH Clinical
Guidelines
Links to an external site.
or APA Clinical Guidelines
Links to an external site.
, research articles, and the role of the PMHNP in your
evaluation.
• Psychiatric Assessment of Infants and ToddlersLinks to an
external site.
• Psychiatric Assessment of Children and AdolescentsLinks
to an external site.
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." An example of
the appropriate descriptors of the clinical evaluation is listed
below. It is not acceptable to document “within normal limits.”
Patient PTSD with Comorbid Depression
1. CPT Code/Time: 90791 (Psychiatric diagnostic evaluation, 30 min)
ICD-10 Code: F43.12 – PTSD, chronic; F32.1 – Major Depressive Disorder, moderate
2. Gender: Male
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
[https://www.nccih.nih.gov/health/providers/clinicalpractice](https://www.nccih.nih.gov/health/providers/clinicalpractice)
[https://www.nccih.nih.gov/health/providers/clinicalpractice](https://www.nccih.nih.gov/health/providers/clinicalpractice)
[https://www.nccih.nih.gov/health/providers/clinicalpractice](https://www.nccih.nih.gov/health/providers/clinicalpractice)
[https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines](https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines)
[https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines](https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines)
[https://www.jaacap.org/article/S0890-8567(09)62592-2/fulltext](https://www.jaacap.org/article/S0890-8567(09)62592-2/fulltext)
[https://www.jaacap.org/article/S0890-8567(09)62592-2/fulltext](https://www.jaacap.org/article/S0890-8567(09)62592-2/fulltext)
[https://www.jaacap.org/article/S0890-8567(09)62591-0/fulltext](https://www.jaacap.org/article/S0890-8567(09)62591-0/fulltext)
[https://www.jaacap.org/article/S0890-8567(09)62591-0/fulltext](https://www.jaacap.org/article/S0890-8567(09)62591-0/fulltext)
3. Insurance: Medicare
4. Ethnicity: Hispanic (Mexican American)
5. Chief Complaint: “I feel empty all the time and can’t stop thinking about the accident.”
6. Explanatory Note: Older adult with PTSD symptoms after a car accident 2 years ago,
complicated by persistent low mood.
7. Race: Hispanic
8. Age: 67
9. Reason for Visit: New consult
10. Social Problems Addressed: Emotional distress, social isolation, loss of independence
after accident
11. Immunizations: Missing shingles vaccine
12. Procedures/Evaluation: PCL-5 = 48; PHQ-9 = 17. MSE: depressed mood, restricted
affect, intact thought process.
13. Principal Diagnosis: PTSD, chronic – F43.12; MDD, moderate – F32.1
14. Differentials:
• F41.1 – GAD (anxiety broad, not trauma-specific)
• F33.1 – MDD, recurrent, moderate (PTSD symptoms primary driver)
• F43.21 – Adjustment Disorder with Anxiety (symptoms persistent beyond 6 months)
15. Treatment: Venlafaxine XR 75 mg PO daily × 30 days, #30, 1 refill.
16. Medication Education: Venlafaxine effective for PTSD and depression. Discussed risk
of hypertension, GI upset, insomnia. Warned about withdrawal with abrupt
discontinuation.
17. Non-Pharmacological: CBT for trauma, supportive psychotherapy for depression.
18. Referrals: Physical therapy for mobility, community senior center for socialization.
19. Follow-up: 6 weeks for mood and trauma symptom response.
20. Vitals: BP 148/88, Temp 98.4°F, HR 82, RR 18, Ht 5’7”, Wt 195 lb, BMI 30.5 (obese)
21. HPI: Patient is a 67-year-old Mexican American male presenting with chronic intrusive
thoughts, nightmares, and avoidance behaviors since a car accident 2 years ago that left
him with mobility limitations. He reports persistent sadness, guilt about the accident,
irritability, and reduced interest in hobbies. He lives alone and rarely sees friends. He
denies hallucinations or suicidal intent. He reports trouble sleeping and fatigue most days.
He seeks help because symptoms interfere with daily functioning and independence.
22. Allergies: NKDA
**GraduateComprehensivePsychiatricEvaluationandPsychotherapyNoteTemplaterev.3112022.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/graduatecomprehensivepsychiatricevaluationandpsychotherapynotetemplaterev-3112022-docx-10519163)
**NUR640CLCPEwk4-2.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/nur640clcpewk4-2-docx)
**PsychiatricSOAPNoteRubric1.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/psychiatricsoapnoterubric1-docx-10519165)
**## NUR650CLCPEInstructionsW2.pdf**
Comprehensive Psychiatric and
Psychotherapy Evaluation 1
Step 1: You will use the Graduate Comprehensive Psychiatric/
Psychotherapy Evaluation Template
Download Graduate Comprehensive Psychiatric/Psychotherapy
Evaluation Template
to:
1. Compose a written comprehensive psychiatric evaluation of
a patient you have seen in the clinic.
2. Upload your completed comprehensive psychiatric
evaluation as a Word doc. Scanned PDFs will not be
accepted.
• For the Comprehensive 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 Evaluation Presentation 1 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
[https://stu.instructure.com/courses/50352/files/4924029?wrap=1](https://stu.instructure.com/courses/50352/files/4924029?wrap=1)
[https://stu.instructure.com/courses/50352/files/4924029?wrap=1](https://stu.instructure.com/courses/50352/files/4924029?wrap=1)
[https://stu.instructure.com/courses/50352/files/4924029?wrap=1](https://stu.instructure.com/courses/50352/files/4924029?wrap=1)
[https://stu.instructure.com/courses/50352/files/4924029/download?download_frd=1](https://stu.instructure.com/courses/50352/files/4924029/download?download_frd=1)
[https://stu.instructure.com/courses/50352/files/4924029/download?download_frd=1](https://stu.instructure.com/courses/50352/files/4924029/download?download_frd=1)
[https://stu.instructure.com/courses/50352/files/4924029/download?download_frd=1](https://stu.instructure.com/courses/50352/files/4924029/download?download_frd=1)
[https://stu.instructure.com/courses/50352/assignments/747635?wrap=1](https://stu.instructure.com/courses/50352/assignments/747635?wrap=1)
Other: Incorporate current clinical guidelines NIH Clinical
Guidelines
Links to an external site.
or APA Clinical Guidelines
Links to an external site.
, research articles, and the role of the PMHNP in your
evaluation.
• Psychiatric Assessment of Infants and ToddlersLinks to an
external site.
• Psychiatric Assessment of Children and AdolescentsLinks
to an external site.
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." An example of
the appropriate descriptors of the clinical evaluation is listed
below. It is not acceptable to document “within normal limits.”
Patient PTSD with Comorbid Depression
1. CPT Code/Time: 90791 (Psychiatric diagnostic evaluation, 30 min)
ICD-10 Code: F43.12 – PTSD, chronic; F32.1 – Major Depressive Disorder, moderate
2. Gender: Male
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
[https://www.nccih.nih.gov/health/providers/clinicalpractice](https://www.nccih.nih.gov/health/providers/clinicalpractice)
[https://www.nccih.nih.gov/health/providers/clinicalpractice](https://www.nccih.nih.gov/health/providers/clinicalpractice)
[https://www.nccih.nih.gov/health/providers/clinicalpractice](https://www.nccih.nih.gov/health/providers/clinicalpractice)
[https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines](https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines)
[https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines](https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines)
[https://www.jaacap.org/article/S0890-8567(09)62592-2/fulltext](https://www.jaacap.org/article/S0890-8567(09)62592-2/fulltext)
[https://www.jaacap.org/article/S0890-8567(09)62592-2/fulltext](https://www.jaacap.org/article/S0890-8567(09)62592-2/fulltext)
[https://www.jaacap.org/article/S0890-8567(09)62591-0/fulltext](https://www.jaacap.org/article/S0890-8567(09)62591-0/fulltext)
[https://www.jaacap.org/article/S0890-8567(09)62591-0/fulltext](https://www.jaacap.org/article/S0890-8567(09)62591-0/fulltext)
3. Insurance: Medicare
4. Ethnicity: Hispanic (Mexican American)
5. Chief Complaint: “I feel empty all the time and can’t stop thinking about the accident.”
6. Explanatory Note: Older adult with PTSD symptoms after a car accident 2 years ago,
complicated by persistent low mood.
7. Race: Hispanic
8. Age: 67
9. Reason for Visit: New consult
10. Social Problems Addressed: Emotional distress, social isolation, loss of independence
after accident
11. Immunizations: Missing shingles vaccine
12. Procedures/Evaluation: PCL-5 = 48; PHQ-9 = 17. MSE: depressed mood, restricted
affect, intact thought process.
13. Principal Diagnosis: PTSD, chronic – F43.12; MDD, moderate – F32.1
14. Differentials:
• F41.1 – GAD (anxiety broad, not trauma-specific)
• F33.1 – MDD, recurrent, moderate (PTSD symptoms primary driver)
• F43.21 – Adjustment Disorder with Anxiety (symptoms persistent beyond 6 months)
15. Treatment: Venlafaxine XR 75 mg PO daily × 30 days, #30, 1 refill.
16. Medication Education: Venlafaxine effective for PTSD and depression. Discussed risk
of hypertension, GI upset, insomnia. Warned about withdrawal with abrupt
discontinuation.
17. Non-Pharmacological: CBT for trauma, supportive psychotherapy for depression.
18. Referrals: Physical therapy for mobility, community senior center for socialization.
19. Follow-up: 6 weeks for mood and trauma symptom response.
20. Vitals: BP 148/88, Temp 98.4°F, HR 82, RR 18, Ht 5’7”, Wt 195 lb, BMI 30.5 (obese)
21. HPI: Patient is a 67-year-old Mexican American male presenting with chronic intrusive
thoughts, nightmares, and avoidance behaviors since a car accident 2 years ago that left
him with mobility limitations. He reports persistent sadness, guilt about the accident,
irritability, and reduced interest in hobbies. He lives alone and rarely sees friends. He
denies hallucinations or suicidal intent. He reports trouble sleeping and fatigue most days.
He seeks help because symptoms interfere with daily functioning and independence.
22. Allergies: NKDA
**GraduateComprehensivePsychiatricEvaluationandPsychotherapyNoteTemplaterev.3112022.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/graduatecomprehensivepsychiatricevaluationandpsychotherapynotetemplaterev-3112022-docx-10519163)
**NUR640CLCPEwk4-2.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/nur640clcpewk4-2-docx)
**PsychiatricSOAPNoteRubric1.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/psychiatricsoapnoterubric1-docx-10519165)