Subjective Data  

Chief Complaint is clear, concise and verbatim from pt. History of Present Illness is thorough yet concise and provides a chronological account of symptoms and contextual factors that are sufficiently descriptive (OLDCARTS) to validate Dx per DSM-5 TR criteria. Include all pertinent negatives. Besides, longitudinal course of illness is clear. Additionally, current psychiatric medications and response are included. 

Objective Data  

MSE contains required elements. Moreover, it is in narrative form and effectively and vividly describes the patient’s presentation. Concrete examples of all assessment results are included i.e. “able to correctly interpret 2/3 simple proverbs” to validate documentation of “abstract thought intact”. 

SOAP Note 

Assessment  

Differential is pertinent to signs and symptoms, formulation contains evidence of critical thought and subject knowledge, and reasonable diagnoses are made per DSM-5. Furthermore, it clearly met criteria for diagnoses tendered are explicit in the HPI (History of Present Illness) description and substantiated with the MSE.   

Plan  

Evidence-based treatment plan is presented with detailed rationales. Additionally, the level of detail reflects the student’s ability to choose treatments based not only on FDA approval or current evidence but also the nuances and unique characteristics of each. Besides, the treatment plan is holistic and comprehensive. There is compelling evidence of the student’s synthesis of information and critical thought. Includes neurobiology information on the disorder   

The format is consistent with the example provided in the course. Clear, recent (5-7 years), scholarly, peer- reviewed support of topics. Minimal grammar, spelling, and punctuation errors. Writing mechanics include minimal awkward or unclear passages but are consistent with formal scholarly work. As a result, there are minimal errors in APA style manuals listed on the course syllabi  

This criterion is linked to a learning outcome

Review of Systems including: