Below is a template for this assignment. Demographic Data Patient’s age and pati

Below is a template for this assignment.
Demographic Data Patient’s age and patient’s gender identity IT MUST BE HIPAA compliant. Subjective Chief Complaint (CC): Place the patient’s CC complaint in Quotes History of Present Illness (HPI): Reason for an appointment today. The events that led to hospitalization or clinic visits today. Include symptoms, relieving factors, and past compliance or non-compliance with medications Any adverse effects from past medication use Sleep patterns – number of hours of sleep per day, early wakefulness, inability to initiate sleep, inability to stay asleep, etc. Suicide or homicide thoughts present Any self-care or Activity of Daily Living (ADL) such as eating, drinking liquids, self-care deficits, or issues noted? Presence/description of psychosis (if psychosis, command or non-command) Past Psychiatric History (PSH): Past psychiatric diagnoses Past hospitalizations Past psychiatric medications use Any non-compliance issues in the past? Any meds that didn’t work for this patient? Family History of Psychiatric Conditions or Diagnoses: Mother/father, siblings, grandparents, or direct relatives Social History:  Include nutrition, exercise, substance use (details of use), sexual history/preference, occupation (type), highest school achievement, financial problems, legal issues, children, and history of personal abuse (including sexual, emotional, or physical). Allergies: To medications, foods, chemicals, and others. Review of Systems (ROS) (Physical Complaints): Any physical complaints by the body system? (Respiratory, Cardiac, Renal, etc.) Objective Mental Status Exam: This is not a physical exam. Mental Status Exam (MSE) Assessment (Diagnosis) Differentials Two (2) differential diagnoses with ICD-10 codes. Must include rationale using DSM-5 Criteria (Required) Why didn’t you pick these as a major diagnosis? Working Diagnosis Final or working diagnosis (1), with ICD-10 code. Must include rationale using DSM-5 criteria required – Which symptoms/signs in the DSM-5 the patient matches mostly) Plan Treatment Plan (Tx Plan): Pharmacologic: Include complete information for each medication(s) prescribed Refill Provided: Include complete information for each medication(s) refilled Patient Education: Including specific medication teaching points Was the risk versus benefit of the current treatment plan addressed for meds or treatment Risk versus benefit of non-FDA approved for working diagnosis – Off-label use of medication education to patient addressed? Prognosis: Make Decision for prognosis: Good, Fair, Poor Provide brief statement lending support for or against the decided prognosis. Therapy Recommendations: Type(s) of therapy recommended. Referral/Follow-up: Did you recommend follow-up with a Psychiatrist, PCP, or other specialist or healthcare professionals? When is the subsequent follow-up? Include the rationale for the F/U recommendation or referral. Reference(s): Include American Psychological Association (APA) formatted references. Include a reference from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) or the accompanying Desk Reference of Diagnostic Criteria from DSM-5. Rubric
Problem-focused SOAP Note
Problem-focused SOAP Note
CriteriaRatingsPts
This criterion is linked to a Learning OutcomeSubjective
25 to >20.0 ptsAccomplished
Subjective data, including the analysis is well organized in a SOAP format, with C/C, Past Psychiatric History, Social History, and other pertinent past and current diagnostic details. SOAP Note is complete, concise, and relevant with no extraneous data.
20 to >15.0 ptsSatisfactory
Subjective data, including the analysis is well organized in a SOAP format, with C/C, Past Psychiatric History, Social History, and other pertinent past and current diagnostic details. Some extraneous data is present, with one minor data point missing
15 to >14.0 ptsNeeds Improvement
Subjective data, including the analysis is not well organized or presented in a varied format. Required data is missing. Too much extraneous data is present, or 2-3 minor data points are missing.
14 to >0 ptsUnsatisfactory
Subjective data, including the analysis is inadequate and is not organized. Objective or other data is mixed into the subjective data. Critical data is missing.
25 pts
This criterion is linked to a Learning OutcomeObjective
25 to >20.0 ptsAccomplished
Objective information, including the Mental Status Exam MSE) is complete, concise, well-organized, and well-written. Includes pertinent psychiatric information. They are organized by MSE list format. No extraneous information is included.
20 to >15.0 ptsSatisfactory
Objective information, including the Mental Status Exam (MSE) is partially incomplete, organized, and satisfactorily written. Includes pertinent psychiatric information with additional extraneous data included. Somewhat organized in MSE list format.
15 to >14.0 ptsNeeds Improvement
Objective information, including the Mental Status Exam (MSE) is incomplete and loosely organized, with improvements required. Relevant psychiatric information is omitted.
14 to >0 ptsUnsatisfactory
Objective information, including the Mental Status Exam is absent or disorganized in presentation, adheres to no specific format, or grossly omits relevant psychiatric information.
25 pts
This criterion is linked to a Learning OutcomeAssessment
25 to >20.0 ptsAccomplished
Assessment with differential Dignosis are correct with DSM-5 code(s) and supported by subjective and objective data. Includes: 1 working Dx and 2 Differential Dx.
20 to >15.0 ptsSatisfactory
Assessment with differential Dignosis are correct with DSM-5 code(s) and supported mainly by subjective and objective data. Missing at least one (1) pertinent subjective ot objective data for the working diagnosis is correct.
15 to >14.0 ptsNeeds Improvement
Diagnosis and/or Differential Dx are correct with DSM-5 code(s) and supported mainly by subjective and objective data. Or differential diagnoses are adequate with an incorrect working diagnosis.
14 to >0 ptsUnsatisfactory
All diagnoses (working and differential diagnoses) are incorrect or are missing based on the subjective and objective data presented.
25 pts
This criterion is linked to a Learning OutcomePlan
25 to >20.0 ptsAccomplished
The plan is well-organized, complete, evidence-based, and patient-centric. It comprehensively addresses each diagnosis and is individualized to the specific patient.
20 to >15.0 ptsSatisfactory
The plan is organized, complete, evidence-based, and patient-centric. It comprehensively addresses each diagnosis and is individualized to the specific patient. The plan is missing 1-2 of the required items.
15 to >14.0 ptsNeeds Improvement
The plan is less organized and is not based on evidence. Fails to address each diagnosis sufficiently or is not individualized or patient-centric The plan is missing more than 2 of the required items.
14 to >0 ptsUnsatisfactory
The plan is disorganized, absent, or missing all the required items.
25 pts
Total Points: 100