Psychiatric Interview Documentation Guide

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

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.