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Home>Homework Answsers>Nursing homework helpnursingpsychpls read attachment one is the insturctions and one is template please do it on a schizophrenic pt23 days ago09.06.202510Report issuefiles (2)soapnoteinstructions.docxsoapnoteetemplate.docxsoapnoteinstructions.docxComprehensive Psychotherapy Evaluation 11. Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.2. OAP 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 ExamA =Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codesP =Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow upMake it sure it is psychotherapy on a patient with anxiety/depressionsoapnoteetemplate.docxComprehensive Psychiatric Evaluation TemplateWith Psychotherapy NoteEncounter date: ________________________Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____Reason for Seeking Health Care: ______________________________________________HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________SI/HI:_______________________________________________________________________________Sleep:_________________________________________Appetite:________________________Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________Current perception of Health: Excellent Good Fair PoorPsychiatric History:Inpatient hospitalizations:DateHospitalDiagnosesLength of StayOutpatient psychiatric treatment:DateHospitalDiagnosesLength of StayDetox/Inpatient substance treatment:DateHospitalDiagnosesLength of StayHistory of suicide attempts and/or self injurious behaviors:____________________________________Past Medical History· Major/Chronic Illnesses____________________________________________________· Trauma/Injury ___________________________________________________________· Hospitalizations __________________________________________________________Past Surgical History___________________________________________________________Current psychotropic medications:_________________________________________ _________________________________________________________________________ _________________________________________________________________________ ________________________________Current prescription medications:_________________________________________ _________________________________________________________________________ _________________________________________________________________________ ________________________________OTC/Nutritionals/Herbal/Complementary therapy:_________________________________________ _________________________________________________________________________ ________________________________Substance use:(alcohol, marijuana, cocaine, caffeine, cigarettes)SubstanceAmountFrequencyLength of UseFamily Psychiatric History:_____________________________________________________Social HistoryLives: Single family House/Condo/ with stairs: ___________Marital Status:________Education:____________________________Employment Status: ______Current/Previous occupation type: _________________Exposure to:___Smoke____ ETOH ____Recreational Drug Use: __________________Sexual Orientation:_______ Sexual Activity: ____Contraception Use: ____________Family Composition:Family/Mother/Father/Alone: _____________________________Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________________________________________________________________________________Health MaintenanceScreening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, DementiaExposures:Immunization HX:Review of Systems (at least 3 areas per system):General:HEENT:Neck:Lungs:Cardiovascular:Breast:GI:Male/female genital:GU:Neuro:Musculoskeletal:Activity & Exercise:Psychosocial:Derm:Nutrition:Sleep/Rest:LMP:STI Hx:Physical ExamBP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (percentile) _____General:HEENT:Neck:Pulmonary:Cardiovascular:Breast:GI:Male/female genital:GU:Neuro:Musculoskeletal:Derm:Psychosocial:Misc.Mental Status ExamAppearance:Behavior:Speech:Mood:Affect:Thought Content:Thought Process:Cognition/Intelligence:Clinical Insight:Clinical Judgment:Psychotherapy NoteTherapeutic Technique Used:Session Focus and Theme:Intervention Strategies Implemented:Evidence of Patient Response:Plan:Differential Diagnoses1.2.Principal Diagnoses1.2.Plan:Diagnosis #1Diagnostic Testing/Screening:Pharmacological Treatment:Non-Pharmacological Treatment:Patient/Family Education:Referrals:Follow-up:Anticipatory Guidance:Diagnosis #2Diagnostic Testing/Screening Tool:Pharmacological Treatment:Non-Pharmacological Treatment:Patient/Family Education:Referrals:Follow-up:Anticipatory Guidance:Signature (with appropriate credentials): __________________________________________Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________DEA#: 101010101 STU Clinic LIC# 10000000Tel: (000) 555-1234 FAX: (000) 555-12222Patient Name: (Initials)______________________________ Age ___________Date: _______________RX ______________________________________SIG:Dispense: ___________Refill:_________________No SubstitutionSignature:____________________________________________________________Rev. 2272022 LMsoapnoteetemplate.docxComprehensive Psychiatric Evaluation TemplateWith Psychotherapy NoteEncounter date: ________________________Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____Reason for Seeking Health Care: ______________________________________________HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________SI/HI:_______________________________________________________________________________Sleep:_________________________________________Appetite:________________________Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________Current perception of Health: Excellent Good Fair PoorPsychiatric History:Inpatient hospitalizations:DateHospitalDiagnosesLength of StayOutpatient psychiatric treatment:DateHospitalDiagnosesLength of StayDetox/Inpatient substance treatment:DateHospitalDiagnosesLength of StayHistory of suicide attempts and/or self injurious behaviors:____________________________________Past Medical History· Major/Chronic Illnesses____________________________________________________· Trauma/Injury ___________________________________________________________· Hospitalizations __________________________________________________________Past Surgical History___________________________________________________________Current psychotropic medications:_________________________________________ _________________________________________________________________________ _________________________________________________________________________ ________________________________Current prescription medications:_________________________________________ _________________________________________________________________________ _________________________________________________________________________ ________________________________OTC/Nutritionals/Herbal/Complementary therapy:_________________________________________ _________________________________________________________________________ ________________________________Substance use:(alcohol, marijuana, cocaine, caffeine, cigarettes)SubstanceAmountFrequencyLength of UseFamily Psychiatric History:_____________________________________________________Social HistoryLives: Single family House/Condo/ with stairs: ___________Marital Status:________Education:____________________________Employment Status: ______Current/Previous occupation type: _________________Exposure to:___Smoke____ ETOH ____Recreational Drug Use: __________________Sexual Orientation:_______ Sexual Activity: ____Contraception Use: ____________Family Composition:Family/Mother/Father/Alone: _____________________________Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________________________________________________________________________________Health MaintenanceScreening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, DementiaExposures:Immunization HX:Review of Systems (at least 3 areas per system):General:HEENT:Neck:Lungs:Cardiovascular:Breast:GI:Male/female genital:GU:Neuro:Musculoskeletal:Activity & Exercise:Psychosocial:Derm:Nutrition:Sleep/Rest:LMP:STI Hx:Physical ExamBP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (percentile) _____General:HEENT:Neck:Pulmonary:Cardiovascular:Breast:GI:Male/female genital:GU:Neuro:Musculoskeletal:Derm:Psychosocial:Misc.Mental Status ExamAppearance:Behavior:Speech:Mood:Affect:Thought Content:Thought Process:Cognition/Intelligence:Clinical Insight:Clinical Judgment:Psychotherapy NoteTherapeutic Technique Used:Session Focus and Theme:Intervention Strategies Implemented:Evidence of Patient Response:Plan:Differential Diagnoses1.2.Principal Diagnoses1.2.Plan:Diagnosis #1Diagnostic Testing/Screening:Pharmacological Treatment:Non-Pharmacological Treatment:Patient/Family Education:Referrals:Follow-up:Anticipatory Guidance:Diagnosis #2Diagnostic Testing/Screening Tool:Pharmacological Treatment:Non-Pharmacological Treatment:Patient/Family Education:Referrals:Follow-up:Anticipatory Guidance:Signature (with appropriate credentials): __________________________________________Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________DEA#: 101010101 STU Clinic LIC# 10000000Tel: (000) 555-1234 FAX: (000) 555-12222Patient Name: (Initials)______________________________ Age ___________Date: _______________RX ______________________________________SIG:Dispense: ___________Refill:_________________No SubstitutionSignature:____________________________________________________________Rev. 2272022 LMsoapnoteinstructions.docxComprehensive Psychotherapy Evaluation 11. Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.2. OAP 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 ExamA =Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codesP =Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow upMake it sure it is psychotherapy on a patient with anxiety/depressionsoapnoteetemplate.docxComprehensive Psychiatric Evaluation TemplateWith Psychotherapy NoteEncounter date: ________________________Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____Reason for Seeking Health Care: ______________________________________________HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________SI/HI:_______________________________________________________________________________Sleep:_________________________________________Appetite:________________________Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________Current perception of Health: Excellent Good Fair PoorPsychiatric History:Inpatient hospitalizations:DateHospitalDiagnosesLength of StayOutpatient psychiatric treatment:DateHospitalDiagnosesLength of StayDetox/Inpatient substance treatment:DateHospitalDiagnosesLength of StayHistory of suicide attempts and/or self injurious behaviors:____________________________________Past Medical History· Major/Chronic Illnesses____________________________________________________· Trauma/Injury ___________________________________________________________· Hospitalizations __________________________________________________________Past Surgical History___________________________________________________________Current psychotropic medications:_________________________________________ _________________________________________________________________________ _________________________________________________________________________ ________________________________Current prescription medications:_________________________________________ _________________________________________________________________________ _________________________________________________________________________ ________________________________OTC/Nutritionals/Herbal/Complementary therapy:_________________________________________ _________________________________________________________________________ ________________________________Substance use:(alcohol, marijuana, cocaine, caffeine, cigarettes)SubstanceAmountFrequencyLength of UseFamily Psychiatric History:_____________________________________________________Social HistoryLives: Single family House/Condo/ with stairs: ___________Marital Status:________Education:____________________________Employment Status: ______Current/Previous occupation type: _________________Exposure to:___Smoke____ ETOH ____Recreational Drug Use: __________________Sexual Orientation:_______ Sexual Activity: ____Contraception Use: ____________Family Composition:Family/Mother/Father/Alone: _____________________________Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________________________________________________________________________________Health MaintenanceScreening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, DementiaExposures:Immunization HX:Review of Systems (at least 3 areas per system):General:HEENT:Neck:Lungs:Cardiovascular:Breast:GI:Male/female genital:GU:Neuro:Musculoskeletal:Activity & Exercise:Psychosocial:Derm:Nutrition:Sleep/Rest:LMP:STI Hx:Physical ExamBP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (percentile) _____General:HEENT:Neck:Pulmonary:Cardiovascular:Breast:GI:Male/female genital:GU:Neuro:Musculoskeletal:Derm:Psychosocial:Misc.Mental Status ExamAppearance:Behavior:Speech:Mood:Affect:Thought Content:Thought Process:Cognition/Intelligence:Clinical Insight:Clinical Judgment:Psychotherapy NoteTherapeutic Technique Used:Session Focus and Theme:Intervention Strategies Implemented:Evidence of Patient Response:Plan:Differential Diagnoses1.2.Principal Diagnoses1.2.Plan:Diagnosis #1Diagnostic Testing/Screening:Pharmacological Treatment:Non-Pharmacological Treatment:Patient/Family Education:Referrals:Follow-up:Anticipatory Guidance:Diagnosis #2Diagnostic Testing/Screening Tool:Pharmacological Treatment:Non-Pharmacological Treatment:Patient/Family Education:Referrals:Follow-up:Anticipatory Guidance:Signature (with appropriate credentials): __________________________________________Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________DEA#: 101010101 STU Clinic LIC# 10000000Tel: (000) 555-1234 FAX: (000) 555-12222Patient Name: (Initials)______________________________ Age ___________Date: _______________RX ______________________________________SIG:Dispense: ___________Refill:_________________No SubstitutionSignature:____________________________________________________________Rev. 2272022 LMsoapnoteinstructions.docxComprehensive Psychotherapy Evaluation 11. Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.2. OAP 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 ExamA =Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codesP =Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow upMake it sure it is psychotherapy on a patient with anxiety/depressionsoapnoteetemplate.docxComprehensive Psychiatric Evaluation TemplateWith Psychotherapy NoteEncounter date: ________________________Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____Reason for Seeking Health Care: ______________________________________________HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________SI/HI:_______________________________________________________________________________Sleep:_________________________________________Appetite:________________________Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________Current perception of Health: Excellent Good Fair PoorPsychiatric History:Inpatient hospitalizations:DateHospitalDiagnosesLength of StayOutpatient psychiatric treatment:DateHospitalDiagnosesLength of StayDetox/Inpatient substance treatment:DateHospitalDiagnosesLength of StayHistory of suicide attempts and/or self injurious behaviors:____________________________________Past Medical History· Major/Chronic Illnesses____________________________________________________· Trauma/Injury ___________________________________________________________· Hospitalizations __________________________________________________________Past Surgical History___________________________________________________________Current psychotropic medications:_________________________________________ _________________________________________________________________________ _________________________________________________________________________ ________________________________Current prescription medications:_________________________________________ _________________________________________________________________________ _________________________________________________________________________ ________________________________OTC/Nutritionals/Herbal/Complementary therapy:_________________________________________ _________________________________________________________________________ ________________________________Substance use:(alcohol, marijuana, cocaine, caffeine, cigarettes)SubstanceAmountFrequencyLength of UseFamily Psychiatric History:_____________________________________________________Social HistoryLives: Single family House/Condo/ with stairs: ___________Marital Status:________Education:____________________________Employment Status: ______Current/Previous occupation type: _________________Exposure to:___Smoke____ ETOH ____Recreational Drug Use: __________________Sexual Orientation:_______ Sexual Activity: ____Contraception Use: ____________Family Composition:Family/Mother/Father/Alone: _____________________________Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________________________________________________________________________________Health MaintenanceScreening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, DementiaExposures:Immunization HX:Review of Systems (at least 3 areas per system):General:HEENT:Neck:Lungs:Cardiovascular:Breast:GI:Male/female genital:GU:Neuro:Musculoskeletal:Activity & Exercise:Psychosocial:Derm:Nutrition:Sleep/Rest:LMP:STI Hx:Physical ExamBP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (percentile) _____General:HEENT:Neck:Pulmonary:Cardiovascular:Breast:GI:Male/female genital:GU:Neuro:Musculoskeletal:Derm:Psychosocial:Misc.Mental Status ExamAppearance:Behavior:Speech:Mood:Affect:Thought Content:Thought Process:Cognition/Intelligence:Clinical Insight:Clinical Judgment:Psychotherapy NoteTherapeutic Technique Used:Session Focus and Theme:Intervention Strategies Implemented:Evidence of Patient Response:Plan:Differential Diagnoses1.2.Principal Diagnoses1.2.Plan:Diagnosis #1Diagnostic Testing/Screening:Pharmacological Treatment:Non-Pharmacological Treatment:Patient/Family Education:Referrals:Follow-up:Anticipatory Guidance:Diagnosis #2Diagnostic Testing/Screening Tool:Pharmacological Treatment:Non-Pharmacological Treatment:Patient/Family Education:Referrals:Follow-up:Anticipatory Guidance:Signature (with appropriate credentials): __________________________________________Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________DEA#: 101010101 STU Clinic LIC# 10000000Tel: (000) 555-1234 FAX: (000) 555-12222Patient Name: (Initials)______________________________ Age ___________Date: _______________RX ______________________________________SIG:Dispense: ___________Refill:_________________No SubstitutionSignature:____________________________________________________________Rev. 2272022 LM12Bids(50)Dr. Ellen RMDr. Aylin JMProf Double Rfirstclass tutorsherry proffMUSYOKIONES A+Dr ClovergrA+de plusSheryl HoganPROF_ALISTERpacesetters2121ProWritingGuruIsabella HarvardWIZARD_KIMYoung Nyanyaabdul_rehman_miss AaliyahYourStudyGuruTutor Cyrus KenPERFECT PROFShow All Bidsother Questions(10)Discussion 3-2Week 4 – Discussion 2Philosophy homeworkStrategic Plan and Self-Reflection Summary – Harley-DavidsonWriting a Training Standard Operating Procedure/Guideline (SOP/SOG)PIVOT Programmers Needed!MIS GROUP PROJECT PAPER PART 4hiaccount tutor onlyHomework

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