Notes are to represent real clients seen by you in clinic and information must also be reflected in your InPlace folder of clinical patients. Information leading to discovery of a “made up” note will be cause for course failure.

Category

Unacceptable

Acceptable

Good

Excellent

Demographic Data

0

Does not adequately convey topic. Missing all or
most key elements.

1

Includes
minimal identifying information. Primary source of information and
reliability as well as reason for referral and patient understanding of
referral are not included or are unclear.

3

Includes identifying information but leaves out
some key elements. Primary source of information and reliability as well as
reason for referral and patient understanding of referral are noted.

5

Includes identifying information including
initials, age, gender, ethnicity. Primary source of information and
reliability as well as reason for referral and patient understanding of referral
are clear.

Subjective Data

History of Present Illness (HPI)

0

CC
is not recorded. HPI does not reflect a chronological account of symptoms
that are sufficiently descriptive to validate Dx per DSM-5 criteria.
Pertinent negatives are not included. The longitudinal course of illness is nonexistent.

8

CC is clear. HPI provides an account of symptoms
that are descriptive, nonchronological, without context, and do not clearly
validate Dx per DSM-5 criteria. Few pertinent negatives are included. A
longitudinal course of illness is unclear. Current medications are included.

14

CC
is clear, concise and verbatim from pt. HPI is thorough yet concise and
provides a chronological account of symptoms with some contextual factors
that are sufficiently descriptive (oldcarts) to validate Dx per DSM-5
criteria. Pertinent negatives are included. A longitudinal course of illness
is appreciable. Current psychiatric medications and response are included.

20

CC
is clear, concise and verbatim from pt. HPI 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 criteria. All
pertinent negatives are included. A longitudinal course of illness is clear.
Current psychiatric medications and response are included.

Past Psychiatric History

0

PPH
contains no previous treatment Hx including previous Dx, hospitalizations,
outpatient treatments, suicide attempts, self-harm, nor is there descriptions
of previous medications with detailed trial and response history. Pertinent
negatives are not included.

1

PPH
contains sparse data regarding previous treatment including previous Dx,
hospitalizations, outpatient treatments, suicide attempts, self-harm. Previous
medication history is sparse and without detailed trial and response history.
Pertinent negatives are unclear.

3

PPH
contains most data regarding previous treatment including previous Dx,
hospitalizations, outpatient treatments, suicide attempts, self-harm, and
previous medications with detailed trial and response history. Pertinent
negatives are also included.

5

PPH
contains all previous treatment including previous Dx, hospitalizations,
outpatient treatments, suicide attempts, self-harm, and previous medications
with detailed trial and response history. Pertinent negatives are also
included.

Substance Use History

0

Substance use history is not documented. No
inclusion of addictive behavioral patterns.

1

Substance use history is documented but data is
sparse. Pertinent negatives are unclear. Age of onset, duration,
frequency/pattern of use, route of administration, last use, consequences of
use are not all included. Not limited to illicit substances. Review of addictive
behavioral patterns absent.

3

Complete substance use history is documented. Most
pertinent negatives are documented. Age of onset, duration, frequency/pattern
of use, route of administration, last use, consequences of use. Not limited
to illicit substances. Inclusive of addictive behavioral patterns.

5

Complete substance use history is documented.
Pertinent negatives are clear evidenced by appropriate pt. responses i.e..
“denies”. Age of onset, duration, frequency/pattern of use, route of
administration, last use, consequences of use. Not limited to illicit
substances. Inclusive of addictive behavioral patterns.

Past Medical History and Review of Systems (ROS)

0

Medical history is incomplete or
absent. ROS is not complete or is not free from objective assessment data i.e..
“lungs clear” “BS present”

1

Medical history includes previous and
current medical problems, surgeries, and allergies. ROS may be extraneous or
incomplete for the presenting psychiatric problems and is not free from
objective assessment data i.e.. “lungs clear” “BS present”

3

Medical
history includes previous and current medical problems, surgeries, and
allergies. ROS is germane to the presenting psychiatric problems but is not
free from objective assessment data i.e.. “lungs clear” “BS present”

5

Medical
history includes previous and current medical problems, surgeries, and
allergies. ROS is germane to the presenting psychiatric problems and is free
from objective assessment data i.e.. “lungs clear” “BS present”.

Family History Psychosocial and Developmental
History

0

Family Hx is minimal or nonexistent and does not include identified
relational status with current or historical psych illness, treatments,
responses, suicides, or self-harm. Dev’t Hx minimally or does not include
info regarding family of origin, siblings, birth order, family dynamics,
relational patterns and status, educational, employment, abuse, spirituality,
legal, military. Dev’t milestones for child & adolescents are not
included

3

Family
Hx includes some of the identified relational status with current or
historical psych illness, treatments, responses, suicides, or self-harm. No indication
if biologically related. Dev’t Hx includes minimal info regarding family of
origin, siblings, birth order, family dynamics, relational patterns and
status, educational, employment, abuse, spirituality, legal, military. Few dev’t
milestones for child & adolescents are included

7

Family
Hx includes current or historical psych illness without clear identification
of relation, but does include treatments, responses, suicides, or self-harm.
Dev’t Hx includes most info regarding family of origin, siblings, birth
order, family dynamics, relational patterns and status, educational,
employment, abuse, spirituality, legal, military. Dev’t milestones for child
&

adolescents
are included

10

Family
Hx includes identified relational status with current or historical psych
illness, treatments, responses, suicides, or self-harm. Indication if
biologically related. Dev’t Hx includes info regarding family of origin,
siblings, birth order, family dynamics, relational patterns and status,
educational, employment, abuse, spirituality, legal, military. Dev’t
milestones for child & adolescents are included

Objective Data

Mental Status Exam Physical Exam (as appropriate)
vital signs, height, weight, labs or other relevant diagnostics.

0

MSE missing
most elements.

Physical exam
not documented

5

MSE contains all elements as outlined in
addendum..

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”.

10

MSE contains all elements as outlined in
addendum..

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”.

15

MSE contains all elements as outlined in
addendum..

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”.

Assessment

0

Differential is impertinent to S&S or absent. Formulation
does not support nor clearly outline thought process of diagnoses. Diagnoses
tendered are not supported by criteria in the HPI description or
substantiated with the MSE.

3

Differential is impertinent to S&S,
formulation appears rudimentary and vague. Diagnoses are made per DSM-5 but
are marginally reasonable. Criteria for diagnoses tendered are not explicit in
the HPI description or substantiated with the MSE.

7

Differential is pertinent to S&S, formulation
contains evidence of critical thought and subject knowledge, and reasonable
diagnoses are made per DSM-5. Clearly met criteria for diagnoses tendered are
explicit in the HPI description and substantiated with the MSE.

10

Differential is pertinent to S&S, formulation
contains evidence of critical thought and subject knowledge, and reasonable
diagnoses are made per DSM-5. Clearly met criteria for diagnoses tendered are
explicit in the HPI description and substantiated with the MSE.

Plan

0

Treatment plan is presented without sound  rationales. There is no evidence of
synthesis of information or critical thought.

5

Evidence-based
treatment plan is presented with minimal rationales. Rationales reflect the
student’s marginal ability to choose treatments based not only on FDA
approval or current evidence but also the nuances and unique characteristics of
each. Treatment plan is reasonable but lacks comprehensiveness. There is minimal
evidence of synthesis of information and critical thought.

10

Evidence-based
treatment plan is presented with rationales. Level of detail reflects the
student’s moderate ability to choose treatments based not only on FDA
approval or current evidence but also the nuances and unique characteristics of
each. Treatment plan is holistic and comprehensive. There is some evidence of
the student’s synthesis of information and critical thought.

15

Evidence-based
treatment plan is presented with detailed rationales. 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. Treatment plan is holistic and comprehensive. There is strong evidence
of the student’s synthesis of information and critical thought.

Writing,
Support, APA

0

The
format is not consistent with the example provided in the course. No recent, scholarly, peer-
reviewed support of topic. Substantial grammar, spelling, and punctuation
errors detracting from the assignment. Writing mechanics include many awkward or unclear passages and
informal tone not consistent with formal scholarly work. Substantial errors in APA
style based upon the required APA manuals listed on the course syllabi.

1

The
format is marginally consistent with the example provided in the course. Limited
recent (5-7 years), scholarly, peer- reviewed support of topics. Occasional
spelling, grammar, and punctuation errors detracting from the assignment.
Writing mechanics include awkward or unclear passages and informal tone not
always consistent with formal scholarly work. Occasional errors in APA style
based upon the required APA manuals listed on the course syllabi.

3

The
format is fairly 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. Minimal errors in APA style manuals listed on the
course syllabi.

5

The
format is consistent with the example provided in the course. Strong, recent (5-7 years), scholarly, peer- reviewed support
of topics. No grammar, spelling, and punctuation errors. Writing mechanics
are consistent with formal scholarly work. No errors in APA style based upon
the required APA manuals listed on the course syllabi.