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Each student will create a focused SOAP note presentation . SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive psychiatric SOAP note is to be written using the attached template below. 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 The presentation is original work and logically organized, formatted, and cited in the current APA style, including citation of references. The video presentation should consist of all 9 pages of the Graduate Psychiatric Soap note Template and is less than 7 minutes in length.  Incorporate a minimum of four current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work. Journal articles and books should be referenced according to APA style, 7th Edition (the library has a copy of the APA Manual). Psychiatric SOAP Note Rubric CriteriaRatingsPts Chief Complaint view longer description 4 to >3 pts Exemplary Includes a direct quote from patient about presenting problem3 to >2 pts Distinguished Includes a direct quote from patient and other unrelated information2 to >0 pts Developing Includes information but information is NOT a direct quote0 pts Novice Information is completely missing/ 4 pts Demographics - S view longer description 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 view longer description 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, Timing2 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, Timing1 to >0 pts Novice The presenting problem is not clearly stated and/or there are 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 view longer description 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 view longer description 3 pts Exemplary 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 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 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 view longer description 4 to >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)3 to >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)2 to >0 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/ 4 pts Past Medical History-S view longer description 3 pts Exemplary Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current2 pts Distinguished Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current1 pts Developing Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current0 pts Novice Information is completely missing/ 3 pts Past Psychiatric History-S view longer description 5 to >3 pts Exemplary Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), year of diagnosis and3 to >2 pts Distinguished Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (omits addiction treatment), year of diagnosis2 to >0 pts Developing Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), does not include the year of diagnosis0 pts Novice The information is completely missing/ 5 pts Family Psychiatric History-S view longer description 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 attempts2 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 attempts1 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 attempts0 pts Novice Information is completely missing/ 3 pts Social History-S view longer description 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 Physical Examination-O view longer description 3 pts Exemplary Includes a minimum of 3 assessments for each body system and assesses at least 5 body systems directed to chief complaint2 pts Distinguished Includes a minimum of3 assessments for each body system and assesses at least 4 body systems directed to chief complaint1 pts Developing Includes a minimum of 2 assessments for each body system and assesses at least 4 body systems directed to chief complaint0 pts Novice Information is completely missing/ 3 pts Mental Status Exam-O view longer description 15 to >8 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 area8 to >5 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 area5 to >3 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 area3 to >0 pts Novice Includes 3 pts Exemplary Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)3 to >2 pts Distinguished Includes a clear outline of the accurate diagnoses addressed at the visit but does not list the diagnoses in descending order of priority2 to >0 pts Developing Includes an inaccurate diagnosis as the principal diagnosis0 pts Novice Information is completely missing/ 5 pts Differential Diagnoses-A view longer description 3 pts Exemplary Includes at least 2 differential diagnoses for the principal diagnosis2 pts Distinguished Includes 2 differential diagnoses for the principal diagnosis1 pts Developing Includes 1 differential diagnosis for the principal diagnosis0 pts Novice Information is completely missing/ 3 pts Outcome Labs/Screening Tools - O view longer description 3 pts Exemplary Includes 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 Includes appropriate diagnostic/lab testing 50% of the time OR acknowledges “no diagnostic testing or screening tool clinically required at this time”1 pts Developing Includes appropriate diagnostic testing less than 50% of the time.0 pts Novice Information is completely missing./ 3 pts Treatment view longer description 5 to >3 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.3 to >2 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.2 to >1 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.1 to >0 pts Novice Information is completely missing/ 5 pts Patient/Family Education-P view longer description 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 view longer description 5 to >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.3 to >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.2 to >0 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./ 5 pts APA Formatting view longer description 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 PowerPoint and/or Video Presentation view longer description 10 pts Exemplary PowerPoint presentation with Canvas Capture contains 10-15 slides. All parts of the assignment are completed fully and described in the PowerPoint presentation in detail. Video presentation is between 5 and 7 minutes. Well spoken, professional and clearly organized using standard English, characterized by elements of a strong oral presentation delivery, e.g., good eye contact, clear audible voice, posed, controlled and smooth delivery with good language skills and pronunciation for > 75% of the time. Seemed to read from notes 25% and <50% of the time. Seemed to read from notes <50% of the time.

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