Child/Adolescent Psychiatric Initial Interview/Assessment
In this assignment, you will complete a comprehensive psychiatric assessment interview of a child/adolescent.
This assessment should NOT be on a patient that you have encountered in your work, but instead, should be a family member or friend. Your assessment should be comprehensive, and you should refer to course texts to inform items for inclusion in your assessment. Keep in mind that you will be responsible for covering those areas addressed in the reading assignments up to this point.
Students always ask for a template. I have included one that can be used to guide you through the process.
Initial Psychiatric SOAP Note Template
There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to develop your style of SOAP in the psychiatric practice setting.
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Criteria |
Clinical Notes |
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Informed Consent |
Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and |
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Subjective |
Verify Patient Name: DOB: Minor: Accompanied by: Demographic: Gender Identifier Note: CC: HPI: Pertinent history in record and from patient: X During assessment: Patient describes their mood as X and indicated it has gotten worse in TIME. Patient self-esteem appears fair, no reported feelings of excessive guilt, no reported anhedonia, does not report sleep disturbance, does not report change in appetite, does not report libido disturbances, does not report change in energy, no reported changes in concentration or memory. Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. Patient does not report excessive fears, worries or panic attacks. Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a characterological nature. SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors. Allergies: NKDFA. (medication & food) Past Medical Hx: Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury. Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C. Surgical history no surgical history reported If Minor obtain Developmental Hx: (most often from parents), in utero, birth and delivery hx, early childhood, school hx, behavior, etc… Nutritional status (this is an important component to gauge
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