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Psychiatric Interview Documentation Guide
Preparing the Assignment
Follow these guidelines when completing each component of the assignment. Contact your course faculty if you have questions.
General Instructions
Download the Psychiatric Interview Template.
Watch the Psychiatric Interview Recording and complete the required psychiatric interview documentation. Client age and allergies have been completed.
Include the following elements:
History of present illness (HPI)
Include the chief complaint in quotation marks
List only HPI data
Use appropriate terminology
Provide support from an appropriate scholarly source or textbook to support content and terminology
Provide information that is understandable, well-organized, and easy to follow
Psychiatric Interview Documentation Guide
Medications
Provide all current medication information
Include all criteria from the medication table
Use appropriate medical terminology
Provide information that is understandable, well-organized, and easy to follow
Past psychiatric history
Include entire past psychiatric history
Address all criteria listed on the template
Use appropriate terminology
Check tips on how to do your SOAP Note Assignment
Provide support from an appropriate scholarly source or textbook to support content and terminology
Provide information that is understandable, well-organized, and easy to follow
Medical history
Include all relevant medical information
Address all criteria listed on the template
Use appropriate terminology
Psychiatric Interview Documentation Guide
Provide support from an appropriate scholarly source or textbook to support content and terminology
Provide information that is understandable, well-organized, and easy to follow
Family History
Include all pertinent family history
Address all criteria listed on the template
Use appropriate terminology
Provide support from an appropriate scholarly source or textbook to support content and terminology
Provide information that is understandable, well-organized, and easy to follow
Social History
Include all relevant information from the social history
Address all criteria listed on the template
Use appropriate terminology
Provide support from an appropriate scholarly source or textbook to support content and terminology
Psychiatric Interview Documentation Guide
Provide information that is understandable, well-organized, and easy to follow
Review of systems (ROS)
Address all ROS criteria listed on the template
Use appropriate terminology
Provide support from an appropriate scholarly source or textbook to support content and terminology
Provide information that is understandable, well-organized, and easy to follow
Mental status examination (MSE)
Include each element of the MSE
Address all criteria listed on the template
Use appropriate terminology
Provide support from an appropriate scholarly source or textbook to support content and terminology
Provide information that is understandable, well-organized, and easy to follow
List items not addressed during the interview and discuss whether listed items were appropriately omitted or should be included. Cite a reference to support the listed items.
Formatting
Carlat’s (2017) textbook is used to support terminology and section content
Sources represent a logical link between the source content and the interview documentation
In-text citations match listed references
Direct quotes are not used
Submit your completed template to the Week 6 Dropbox.