How to Write a Comprehensive Psychiatric Evaluation and SOAP Note
A rubric-aligned guide for graduate nursing and PMHNP students. From writing a complete HPI with OLDCARTS, to documenting all 10 MSE components, to formulating a DSM-5-TR diagnosis — here is what the assignment actually requires and how to approach each section without losing points.
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Get Expert Help →What the Comprehensive Psychiatric Evaluation Assignment Requires
A comprehensive psychiatric evaluation is a structured clinical document in SOAP format that captures your patient’s presenting complaint, full psychiatric and medical history, Mental Status Exam, a primary diagnosis with ICD-10 and DSM-5-TR codes, two differential diagnoses, a pharmacologic and non-pharmacologic treatment plan, patient education, referrals, and evidence from a minimum of four current scholarly sources — all presented as your own independent clinical reasoning, not your preceptor’s conclusions.
Let’s be direct about what this assignment is testing. It is not asking whether you can copy what your preceptor wrote. It is asking whether you can independently gather data, document it in a format that meets clinical and billing standards, synthesize it into a psychiatric diagnosis, and build a treatment plan supported by current evidence. Two things disqualify a submission immediately: writing “within normal limits” anywhere in the Mental Status Exam, and attributing your diagnosis to your preceptor instead of defending it yourself.
The rubric has specific point thresholds for every section. The Mental Status Exam alone is worth 15 points. The primary diagnosis is worth 11. Miss the mark on those two and you have already lost more than a quarter of the grade. This guide walks through each section so you know what “Exemplary” looks like before you start writing — not after you get your grade back.
Two Automatic Point Losses
The assignment instructions are explicit: you cannot write “within normal limits” anywhere in the evaluation — document the actual descriptive findings. And you cannot write “my preceptor made this diagnosis” — the evaluation must reflect your own clinical reasoning. Both will drop you from Exemplary to Developing or lower on multiple rubric items.
The SOAP Format: What Goes Where in a Psychiatric Note
SOAP stands for Subjective, Objective, Assessment, and Plan. Every element of the evaluation maps to one of these four sections. The template your program provides follows this structure exactly. Get the mapping right before you write a single word — putting something in the wrong section (putting diagnoses in the Objective section, for example) signals that you do not understand clinical documentation, and it costs points.
Subjective
Chief complaint (patient’s own words in quotes), demographics, HPI with OLDCARTS, allergies, psychiatric history, past medical and surgical history, current medications, substance use, family psychiatric history, social history, Review of Systems.
Objective
Vital signs (all 8), labs and screening tools with values and abnormal flags, Mental Status Exam with detailed descriptive findings for all 10 components, and physical exam if performed.
Assessment
Primary diagnosis listed first with DSM-5-TR criteria cited and correct ICD-10 code. All other diagnoses addressed at the visit in descending priority. At least 2 differential diagnoses supported by your S and O data, each with ICD-10 codes.
Plan
Pharmacologic plan (drug name, dose, route, frequency, duration, cost, medication education). Non-pharmacologic plan (therapy type, frequency, duration). Labs ordered. Patient/family education — at least 3 strategies. Referrals and follow-up timeline.
The Video Presentation: What It Adds
Step 2 of the assignment requires a SOAP note video presentation under 7 minutes. You share the document on screen and discuss your findings — you do not read it word for word. The expectation is that you can talk about your clinical reasoning: why this diagnosis fits the data, what evidence supports your treatment choices, and how APA or NIH clinical guidelines informed your plan. Practice narrating your reasoning, not reciting your note.
The Subjective Section: Starting Strong With Demographics and Chief Complaint
The Subjective section has more rubric line items than any other part of the note. Demographics, chief complaint, HPI, allergies, ROS, medications, past psychiatric history, family psychiatric history, and social history all live here. Most students lose points not because they omit a section entirely, but because they do it at a “Developing” level when “Exemplary” was one sentence away.
Demographics — 2 Points Available
The note must begin with patient initials, age, race, ethnicity, and gender. All five. Missing even one drops you from 2 to 1.5 points. This is the easiest 2 points in the assignment. Example opening line: “S.M. is a 34-year-old African American, non-Hispanic, cisgender female presenting with…” — that hits all five demographics in one clause.
Chief Complaint — 4 Points Available
Use a direct quote from the patient. Literally put it in quotation marks. That is the Exemplary standard. “Feeling depressed and not sleeping” — in quotes, attributed to the patient. If you paraphrase instead of quoting, you drop to Developing. Four points for one quoted sentence. Write it down exactly as the patient said it during the encounter.
Allergies — 2 Points Available
List every allergy by category (drug, environmental, food, herbal, latex). For each allergy that is present, include the allergy name, the severity, and a description of the reaction. If no allergies exist, write NKA — no known allergies — and specify each category: no known drug, environmental, food, herbal, or latex allergies. Omitting severity or reaction description drops you to Distinguished.
Review of Systems — 5 Points Available
The ROS must cover at least 9 body systems directed to the chief complaint. Each system needs a minimum of 3 assessments. Use the words “admits” and “denies” — the rubric calls this out explicitly. If you do not use those two words, you cannot score in the Exemplary or Distinguished range. Example: “Neurological: Patient denies headache, denies numbness, and admits to difficulty concentrating.”
Social History — 11 Data Points, 3 Points Available
Exemplary social history includes all 11 items: tobacco use, drug use, alcohol use, marital status, employment status, current occupation, previous occupation, sexual orientation, sexual activity status, contraceptive use or pregnancy status, and living situation. Write it as prose or a structured list — just make sure all 11 are addressed. Many students hit 8 or 9 and stop there, landing in Distinguished instead of Exemplary.
Past Psychiatric History — 4 Points Available
Document both outpatient treatment and hospitalizations. For each psychiatric diagnosis, include the year of diagnosis. Include addiction treatment history. The rubric specifically mentions that omitting addiction treatment history drops you to Distinguished even if everything else is right. If the patient has no psychiatric history, document that explicitly — do not leave this section blank.
Family Psychiatric History — 4 Points Available
Assess at least 6 family members. For each, address genetic disorders, mood disorders, bipolar disorder, and history of suicide attempts at minimum. Fewer than 6 family members drops you to Distinguished. Fewer than 4 drops you to Developing. This takes more than one line — write it out fully, member by member.
The HPI and OLDCARTS: The 8 Dimensions You Cannot Skip
The HPI is worth 5 points and is where most students lose the most ground. The rubric is clear: Exemplary requires the presenting problem plus all 8 dimensions of OLDCARTS. Missing 2 dimensions drops you to Distinguished. Missing 4 drops you to Developing. It is not a vague narrative — it is a structured account of 8 specific data points wrapped in clinical language.
When did the symptoms first start? Gradual or sudden? Any identifiable trigger or precipitating event?
Where is the symptom experienced? For psychiatric complaints: where does the patient feel it — head, chest, body? Radiating?
How long does each episode last? How long has this been going on in total? Continuous or episodic?
What does it feel like? Describe the quality — sad, empty, numb, flat, racing thoughts, irritable? Patient’s own description.
What makes it worse? Stressors, social situations, lack of sleep, specific triggers, environments?
What helps? Medication, sleep, social support, activities, avoidance? Has anything worked before?
When does it occur? Morning vs. evening? Time of year? After specific events? Pattern over time — worsening, stable, improving?
Rate on a 0–10 scale. How is it affecting daily function — work, relationships, sleep, self-care, ADLs?
Address SI/HI immediately after the HPI. Document whether the patient reports suicidal ideation or homicidal ideation, and if present, document whether there is a plan, means, and intent. This is not just a rubric requirement — it is a clinical and legal documentation standard.
A well-written psychiatric HPI tells a story. It answers: who is this person, what brought them here today, and how did this get to this point? OLDCARTS gives you the scaffold. Your job is to write it so that someone who has never met the patient could understand the full picture.
— Graduate Psychiatric Nursing Clinical FacultyThe HPI also needs to document sleep and appetite separately — the template lists them as distinct fields. Do not bury them in the ROS. Document sleep pattern, quality, number of hours, insomnia or hypersomnia. Document appetite changes, weight changes, and eating patterns. These two are disproportionately important for psychiatric diagnoses like MDD, bipolar disorder, and anxiety spectrum disorders.
The Objective Section: Vital Signs, Labs, and Screening Tools
The Objective section is where you document what you measured and observed — not what the patient told you. Three rubric items live here: vital signs, labs and screening tools during the visit, and screening tools ordered after the visit.
Vital Signs — 2 Points, 8 Required
Exemplary requires all 8 vital signs: blood pressure (with patient position — sitting, standing, or supine), heart rate, respiratory rate, temperature (with the scale — Fahrenheit or Celsius — and route of collection), weight, height, BMI, and pain score. Missing two drops you to Distinguished. Missing four drops you to Developing. Note the patient’s position when taking BP — that detail is explicitly in the rubric and consistently omitted.
| Vital Sign | What to Document | Common Miss |
|---|---|---|
| Blood Pressure | Numeric reading plus patient position (sitting/standing/supine) | Omitting patient position |
| Heart Rate | Rate per minute and rhythm (regular/irregular) | Documenting only rate, no rhythm |
| Respiratory Rate | Breaths per minute | Often omitted in psych visits |
| Temperature | Numeric value, scale (°F or °C), and route (oral, tympanic, axillary) | Missing scale and/or route |
| Weight | In lbs or kg — specify the unit | No unit specified |
| Height | In inches or cm — specify the unit | No unit specified |
| BMI | Calculated value — flag if outside normal range | Omitted or uncalculated |
| Pain | 0–10 numeric scale rating | Omitted because “it’s a psych visit” |
Labs and Screening Tools — 3 Points During Visit, 3 Points After Visit
During the visit: list every lab or screening tool reviewed, include the actual values, and flag abnormal results. If no labs were reviewed, document that explicitly: “No labs reviewed at this visit.” Listing tools without values drops you to Distinguished. After the visit: order appropriate follow-up labs or screening tools. If none are clinically needed, document: “No diagnostic testing or screening tool clinically required at this time.” Leaving this blank costs 3 points.
Common Psychiatric Screening Tools to Know
- PHQ-9 — Patient Health Questionnaire for depression severity (score 0–27)
- GAD-7 — Generalized Anxiety Disorder scale (score 0–21)
- MDQ — Mood Disorder Questionnaire for bipolar screening
- PCL-5 — PTSD Checklist for DSM-5
- AUDIT-C — Alcohol use disorder screening
- DAST-10 — Drug Abuse Screening Test
- Columbia Suicide Severity Rating Scale (C-SSRS) — suicide risk assessment
Document the tool name, the score, and interpret what the score means. A PHQ-9 of 18 = “severe depression” — write that interpretation, not just the number.
The Mental Status Exam: All 10 Components With Descriptive Narratives
The MSE is worth 15 points. It is the largest single rubric item in the entire evaluation. Exemplary requires all 10 components with detailed descriptions for each. Dropping to 8 components costs you 3+ points. Dropping below 6 loses you more than a third of the total MSE points. And the most common mistake is writing one-word labels — “mood: depressed” — instead of clinical narratives that support your conclusion.
Every component of the MSE needs two things: descriptive clinical language that captures what you observed, and a conclusion supported by that description. “Thought process: linear and goal-directed” is better than nothing, but “Thought process is linear and goal-directed; patient responds to questions with relevant, organized responses without tangentiality or circumstantiality” is what earns Exemplary.
Appearance
Document grooming, dress, hygiene, facial expression, height/weight estimate, notable features (tattoos, piercings, scars), nutritional status, and whether apparent age matches stated age. Each of these is a separate observation.
Attitude / Behavior
How did the patient relate to you? Cooperative, guarded, evasive, friendly, seductive, apathetic? Eye contact quality — sustained, poor, avoidant? Psychomotor activity — was the patient restless, slowed, agitated, pacing, wringing hands?
Mood
This is the sustained subjective emotional state the patient reports. Ask directly and quote: “Patient reports mood as ‘really down and empty.'” Describe consistency over the day or week. Mood is what the patient tells you — not what you observe.
Affect
This is what you observe — the emotional expression visible in facial expression and behavior. Document range (full vs. restricted/constricted/flat), intensity (blunted, labile, appropriate, flat), and congruence — does the affect match the thought content?
Speech
Document two dimensions: quality (tone, volume, rate, pronunciation — clear, slurred, mumbled, stuttered, lisped) and quantity (freely verbal, monosyllabic, pressured, hyperverbal, minimal). Both are required for full credit.
Thought Process
This is how the patient thinks — the organization and flow of ideas. Is it linear, logical, goal-directed? Or disorganized, tangential, circumstantial, with flight of ideas, thought blocking, or loose associations? Give an example from the conversation.
Thought Content / Perception
What the patient is thinking about. Document SI/HI with plan and means. Document delusions if present — describe the type and content. Document hallucinations by sensory modality (auditory, visual, tactile, olfactory). Document illusions. If absent, document “denies” for each.
Cognition
Orientation to person, place, and time. Memory — remote, recent past, immediate recall (3-word test), and delayed recall. Concentration and attention — document your clinical test (serial 7s, spelling WORLD backwards). Abstract thinking — use a proverb or similarity task. Fund of knowledge.
Insight
Does the patient understand they have a mental health condition? Do they understand how it is affecting their life and relationships? Scale: good (fully aware), fair (partial awareness), poor (minimal to no awareness). Support with a clinical observation.
Judgment
Can the patient make safe, socially appropriate decisions? What is their plan for after this visit? How do they respond to a hypothetical judgment scenario? Document their answer and your clinical conclusion: good, fair, or poor — and why.
The “Within Normal Limits” Problem
Writing “within normal limits” or “WNL” for any MSE component is explicitly prohibited in this assignment. It tells the reader nothing. Every MSE component must have a descriptive narrative that documents what you actually observed and why you reached the conclusion you reached. “Cognition: within normal limits” gives no clinical information. “Patient oriented to person, place, and time; recalls 3/3 words immediately and 3/3 after 5 minutes; able to interpret the proverb ‘don’t count your chickens before they hatch’ abstractly — indicating intact cognition” does.
The Assessment: Diagnosis, Differentials, and DSM-5-TR
The Assessment section is where your clinical reasoning becomes visible. You are formulating a psychiatric diagnosis using DSM-5-TR criteria, assigning the correct ICD-10 billing code, listing all diagnoses addressed in this visit in order of clinical priority, and providing at least 2 differential diagnoses supported by your subjective and objective data. This is worth 14 combined points — 11 for the primary diagnosis and 3 for differentials.
How to Write the Primary Diagnosis
State the Primary Diagnosis First, With DSM-5-TR Code
The primary diagnosis is the condition most responsible for this visit. List it first. Use the exact DSM-5-TR diagnostic name and the corresponding ICD-10 code. Example: “Major Depressive Disorder, single episode, moderate (ICD-10: F32.1)”. The ICD-10 code must be correct and match the DSM-5-TR specifier. Wrong or missing codes drop you from Exemplary.
List All Diagnoses Addressed at the Visit in Descending Priority
If you also addressed hypertension, Type 2 diabetes, or an anxiety disorder during this visit, list every one of them — in order of clinical priority, with ICD-10 codes. Exemplary means the list is complete and sequenced correctly. Do not list only the psychiatric diagnosis if you also addressed medical conditions — billing and documentation standards require all conditions addressed.
Provide 2 Differential Diagnoses Supported by Your Data
Differential diagnoses are conditions you considered and ruled out — or kept on the list for monitoring. Each differential must be supportable by something in your S and O data. Do not list a differential that has no basis in your documented findings. Use DSM-5-TR criteria to show why the differential fits partially but does not fully meet the primary diagnosis threshold. Include the ICD-10 code for each differential.
DSM-5-TR vs. ICD-10: What You Need to Know
The DSM-5-TR (Text Revision, 2022) is the diagnostic manual. It gives you the diagnostic criteria, specifiers, and clinical descriptions. The ICD-10 (International Classification of Diseases, 10th Revision) gives you the billing code that goes in the legal record. You need both. When you cite diagnostic criteria for your assessment, reference the DSM-5-TR. When you assign a code, use the ICD-10. Your clinical guidelines — APA or NIH — support your treatment plan, not the diagnosis itself.
The Plan: Pharmacologic, Non-Pharmacologic, Education, and Referral
The Plan section is worth a combined 21 points across four rubric items — treatment (10), patient/family education (5), referral (3), and outcome labs (3). It is also where students most commonly lose points by being vague. “Start an SSRI” is not a treatment plan. “Sertraline 50 mg PO QD for 4 weeks; estimated cost $10/month generic at major pharmacy; counsel patient on 4–6 week onset of antidepressant effect, sexual side effects, and not to discontinue abruptly” — that is a treatment plan.
Pharmacologic Treatment Plan
Required for every diagnosis listed in your Assessment
- Drug name — generic and brand name
- Dose — starting dose, titration schedule if applicable
- Route — oral, IM, sublingual, transdermal, etc.
- Frequency — QD, BID, TID, PRN with specific instructions
- Duration — how long the prescription is for; when to reassess
- Cost — approximate generic cost, insurance considerations, patient assistance programs if relevant
- Patient education on the medication — expected onset, common side effects, serious adverse effects, what to do if a dose is missed, black box warnings if applicable
- Support with current U.S. clinical guidelines — cite APA Practice Guidelines or NIMH recommendations for your drug choice
Non-Pharmacologic Treatment Plan
Required for every diagnosis — cannot be omitted
- Therapy type — Cognitive-Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), Motivational Interviewing, Exposure and Response Prevention (ERP), Interpersonal Therapy (IPT), etc.
- Frequency — weekly, biweekly, as clinically indicated
- Duration — short-term (8–12 sessions) vs. open-ended; specify based on diagnosis and clinical guidelines
- Support with evidence — cite a study or guideline that supports your therapy choice for this specific diagnosis
- Other non-pharmacologic options: sleep hygiene protocol, exercise recommendations, support groups, mindfulness-based interventions — include as adjuncts if clinically supported
Patient and Family Education
5 points — needs at least 3 strategies and 3 self-management methods
- 3 strategies to develop illness management skills — how to recognize warning signs of relapse, how to use a mood journal, crisis planning and safety resources
- 3 self-management methods for healthy behaviors — sleep hygiene, regular exercise, dietary changes, limiting alcohol, social support engagement
- Psychoeducation about the diagnosis itself — what is MDD/GAD/PTSD, how does it develop, what is the expected treatment trajectory
- Medication adherence counseling — what to expect, when to call if symptoms worsen, not stopping medication without provider guidance
- Family involvement — when appropriate, include family or support persons in the education plan
Referrals and Follow-Up — 3 Points
List every referral you are making. Specify the type of provider and the reason: referral to outpatient psychotherapy (CBT) for MDD; referral to primary care for medication reconciliation; referral to substance use treatment if indicated. If no referral is needed, document: “No referral advised at this time.” Include a specific follow-up timeline: “Return to clinic in 4 weeks to reassess medication response and tolerability; sooner if symptoms worsen or safety concerns arise.” No timeline = drop to Developing.
Clinical Guidelines That Support Your Plan
The assignment requires current clinical guidelines to support your treatment plan. The two most relevant sources for psychiatric practice are the American Psychiatric Association (APA) Clinical Practice Guidelines and the NIH Clinical Practice Guidelines. Both are free, publicly accessible, and regularly updated. Cite the specific guideline that supports your drug choice, therapy recommendation, or monitoring interval — not just “per clinical guidelines” as a vague attribution.
Rubric Points You Are Probably Losing — and How to Stop
The gap between a B and an A on this assignment usually comes down to four or five specific omissions that are easy to fix once you know what to look for. None of these require additional clinical knowledge — they require knowing the rubric before you write, not after.
What Exemplary Looks Like
- Chief complaint in the patient’s direct words, in quotation marks
- All 5 demographics in the first sentence
- All 8 OLDCARTS dimensions addressed in the HPI
- ROS uses “admits” and “denies” for every system
- 9+ body systems in the ROS, 3+ assessments each
- All 8 vital signs with BP position and temperature route
- Lab values documented with abnormals flagged
- All 10 MSE components with descriptive narratives
- SI/HI assessed with plan, means, and intent documented
- Primary diagnosis with DSM-5-TR and ICD-10 code
- 2 differentials supported by S and O data, with ICD-10 codes
- Drug plan: name, dose, route, frequency, duration, cost, education
- Non-pharmacologic plan with therapy type, frequency, duration
- 3 education strategies + 3 self-management methods
- Referral list or “no referral advised at this time”
- Follow-up timeline specified
- 4 current peer-reviewed sources, APA 7th edition
Where Students Lose Points
- “Within normal limits” anywhere in the MSE
- “My preceptor diagnosed…” instead of own reasoning
- Missing BP position or temperature route in vitals
- ROS without “admits” and “denies” language
- Fewer than 6 family members in family psychiatric history
- Missing addiction history in past psychiatric history
- Social history missing sexual orientation or contraception
- Drug plan missing cost or patient education
- No non-pharmacologic plan listed
- Only 1 differential diagnosis instead of 2
- Differentials without ICD-10 codes
- No follow-up timeline in referral section
- Blank outcome labs section instead of “none required”
- Fewer than 4 references or references older than 5 years
- References not following APA 7th edition format
- Diagnoses not listed in descending priority order
What to Cite and Where
The assignment requires in-text citations throughout and a minimum of 4 current scholarly sources. Use citations in three places: in the Assessment when you cite DSM-5-TR diagnostic criteria, in the Plan when you reference a clinical guideline for your drug or therapy choice, and in the patient education section when citing evidence for a recommended behavior change. Also cite the two JAACAP articles the assignment links for pediatric or adolescent presentations. Use nursing assignment help resources if APA 7th edition formatting is a weak spot — a single reference page error costs points across three rubric items.
FAQs: What Students Ask About the Psychiatric Evaluation Assignment
Writing the Evaluation: Where to Start and What to Prioritize
Start with the MSE. It is worth the most points and takes the longest to write well. Do it first while the encounter is fresh. Every observation you document in the MSE feeds directly into your Assessment — your thought process findings support your diagnosis, your cognition findings rule in or out organic etiologies, your thought content findings determine your safety plan.
Then write the HPI. Make sure all 8 OLDCARTS dimensions are present before you move on. If you realize during the HPI that you missed collecting one of the dimensions during the encounter, document what you were able to assess and note what additional history would clarify the picture — that is better than fabricating data you did not gather.
The Assessment comes last — after you have documented all your subjective and objective findings. Your diagnosis should emerge from the data you collected, not the other way around. If you formulate the diagnosis before you write the S and O sections, you risk reverse-engineering your documentation to fit a conclusion rather than letting the evidence drive the reasoning — and experienced faculty will notice.
For help writing psychiatric SOAP notes, completing a nursing case study, navigating APA citations, or getting feedback on your clinical reasoning before submission, the team at Smart Academic Writing includes PMHNP-qualified writers who understand both what the rubric requires and what the clinical context demands.