Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you examined during the last 4 weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.
Select an adult patient that you examined during the last 4 weeks who presented with a disorder other than the disorder present in your Week 3 Case Presentation.
- Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.
Please Note:- All SOAP notes must be signed, and each page must be initialed by your Preceptor.
Note: Electronic signatures are not accepted. - When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor.
- You must submit your SOAP note using SafeAssign.
Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.
- All SOAP notes must be signed, and each page must be initialed by your Preceptor.
- Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record.
- Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
- Ensure that you have the appropriate lighting and equipment to record the presentation.
Specifically address the following for the patient, using your SOAP note as a guide:
- Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
- Objective: What observations did you make during the psychiatric assessment?
- Assessment: Discuss patient mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.
- Plan: In your video, describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session?
- In your written plan include all the above as well as include one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
- Reflection notes: What would you do differently with this patient if you could conduct the session over? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6665: PMHNP Care Across the Lifespan I
Faculty Name
Assignment Due Date
Subjective:
CC (chief complaint):
HPI:
Substance Current Use:
Medical History:
· Current Medications:
· Allergies:
· Reproductive Hx:
ROS:
· GENERAL:
· HEENT:
· SKIN:
· CARDIOVASCULAR:
· RESPIRATORY:
· GASTROINTESTINAL:
· GENITOURINARY:
· NEUROLOGICAL:
· MUSCULOSKELETAL:
· HEMATOLOGIC:
· LYMPHATICS:
· ENDOCRINOLOGIC:
Objective:
Diagnostic results:
Assessment:
Mental Status Examination:
Diagnostic Impression:
Reflections:
Case Formulation and Treatment Plan:
References
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NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to include, follow the Focused SOAP Note Evaluation Template
AND
the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. After reviewing full details of the rubric, you can use it as a guide.
In the Subjective section, provide:
· Chief complaint
· History of present illness (HPI)
· Past psychiatric history
· Medication trials and current medications
· Psychotherapy or previous psychiatric diagnosis
· Pertinent substance use, family psychiatric/substance use, social, and medical history
· Allergies
· ROS
Read rating descriptions to see the grading standards!
In the Objective section, provide:
· Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
· Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
Read rating descriptions to see the grading standards!
In the Assessment section, provide:
· Results of the mental status examination,
presented in paragraph form.
· At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis.
Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case
.
· Read rating descriptions to see the grading standards!
Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (
demonstrate critical thinking beyond confidentiality and consent for treatment
!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
(The FOCUSED SOAP psychiatric evaluation is typically the follow-up visit patient note. You will practice writing this type of note in this course. You will be focusing more on the symptoms from your differential diagnosis from the comprehensive psychiatric evaluation narrowing to your diagnostic impression. You will write up what symptoms are present and what symptoms
Chief Complaint inpatient psychiatric evaluation for depression with suicidal ideation
Legal Status:
voluntary and capacitated History of Present Illness 25 year old male with past psychiatric history of unspecified mood disorder (with history of mania) and psychosis (both likely medication/substance-induced) who presented voluntarily secondary to depression and active SI and reporting attempted OD with Wellbutrin 2 days ago. He did not seek medical/psychiatric attention until presenting to crisis because he “did not have the strength.” He endorsed significant depressed mood, insomnia, anhedonia, hopelessness, helplessness, decreased energy, decreased concentration, decreased appetite, and suicidal ideation. He endorsed previous suicide attempts via OD. There was no evidence of mania/hypomania or psychosis. He was subsequently admitted to MDU for psychiatric stabilization and management.
The patient was seen this morning, discussed with the ancillary staff, and the chart was reviewed.
Upon interview today, the patient is lying in bed, appearing sleepy, in no acute distress, appearing dysphoric, slightly irritable, and with restricted affect. He says that he attempted to overdose on bottle of Wellbutrin (cannot quantify how many pills) 2 days prior to admission because he was just released from jail about 2-3 weeks ago, has been homeless since, and “couldn’t live like that anymore.” He says he has been feeling significantly and severely overwhelmed by this. He says during the time between being released from jail and presentation to hospital that he was homeless, he was having significantly depressed mood, anhedonia, insomnia, decreased appetite, decreased energy, decreased concentration, worthlessness, hopelessness, helplessness, and active suicidal ideation. He endorses about 3-4 previous suicide attempts via OD, but cannot recall exactly when last one was, however says that it was about 2-3 years ago. He says that since admission yesterday, he has been having good appetite, sleeping well but says “maybe a little too much,” and feels safe here in the hospital. He says he does still feel “depressed.” He also endorses consistent and current everyday use of cocaine, methamphetamines, and marijuana. DAU on admission positive for cannabis and cocaine. On chart review, the majority of psychiatric admission were in the context of substance use as evidenced by positive DAUs at the time of those admissions. He says that he desires inpatient rehabilitation. He relates that prior to being in jail for about a week, he was living with some family he has that live in Miami, however he will not be able to return there upon discharge as “they don’t want me back.” He does not endorse current SI/HI, AVH, paranoia, or symptoms of mania/hypomania. He reports inconsistent medication compliance with his current psychotropic medication regimen of Wellbutrin XR 300 mg daily and Abilify 15 mg daily. He has no somatic complaints.
Of note
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