Comprehensive Psychiatric and/or Psychotherapy Evaluation 3 Step 1: You will use the Graduate Comprehensive Psychiatric/Psychotherapy Evaluation Template Download Graduate Comprehensive

Criteria

Ratings

Points

Chief
Complaint (Reason for seeking health care) – S

4 to
>3.0 points

Exemplary

Includes
a direct quote from patient about presenting problem.

3 to
>2.0 points

Distinguished

Includes
a direct quote from patient and other unrelated information.

2 to
>0.0 points

Developing

Includes
information but information is NOT a direct quote.

0 points

Novice

Information
is completely missing.

4 points

Demographics
– S

2 points

Exemplary

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

1.5 points

Distinguished

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

1 points

Developing

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

0 points

Novice

Information is completely missing.

2 points

History
of the Present Illness (HPI) – S

5 to >3.0 points

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 >2.0 points

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 >1.0 points

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 points

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 points

Allergies
– S

2 points

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 points

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 points

Developing

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

0 points

Novice

Information is completely missing.

2 points

Review
of Systems (ROS) – S

5 to >3.0 points

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 >2.0 points

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 >0.0 points

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 points

Novice

Information is completely missing.

5 points

Vital
Signs – O

2 points

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 points

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 points

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 points

Novice

Information
is completely missing.

2 points

Labs,
Diagnostic Tests and Screening Tools – O

3 points

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 points

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 points

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 points

Novice

Information is completely missing.

3 points

Medications-S

3 points

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 points

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 points

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 points

Novice

Information is completely missing.

3 points

Past
Medical History-S

3 points

Exemplary

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

2 points

Distinguished

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

1 points

Developing

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

0 points

Novice

Information is completely missing.

3 points

Past
Psychiatric History-S

4 to >3.0 points

Exemplary

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

3 to >2.0 points

Distinguished

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

2 to >0.0 points

Developing

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

0 points

Novice

The information is completely missing.

4 points

Family
Psychiatric History-S

4 to >3.0 points

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 >2.0 points

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 >0.0 points

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 points

Novice

Information is completely missing.

4 points

Social
History-S

3 points

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 points

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 points

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 points

Novice

Information is completely missing.

3 points

Mental
Status Exam-O

15 to >12.0 points

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 >10.0 points

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 >0.0 points

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 points

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 points

Primary
Diagnoses-A

11 to >6.0 points

Exemplary

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

6 to >3.0 points

Distinguished

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

3 to >0.0 points

Developing

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

0 points

Novice

Information is completely missing.

11 points

Differential
Diagnoses-A

3 points

Exemplary

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

2 points

Distinguished

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

1 points

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 points

Novice

Information is completely missing.

3 points

Outcome
Labs/Screening Tools – O

3 points

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 points

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 points

Developing

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

0 points

Novice

Information is completely missing.

3 points

Treatment

10 to >8.0 points

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 >6.0 points

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 >0.0 points

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 points

Novice

Information is completely missing.

10 points

Patient/Family
Education-P

5 to >3.0 points

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 >2.0 points

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 >0.0 points

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 points

Novice

Information is completely missing.

5 points

Referral

3 points

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 points

Distinguished

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

1 points

Developing

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

0 points

Novice

Information is completely missing.

3 points

APA
Formatting

5 to >3.0 points

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 >2.0 points

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 >0.0 points

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 points

Novice

APA style and writing mechanics not
used.

5 points

References

5 to >3 points

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 points

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 points

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 points

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 points