Assignment 2: focused soap note and patient case presentation

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 PLEASE FOLLOW INSTRUCTIO BELOW, ZERO PLAGIARISM, FIVE REFERENCES NOT MORE THAN FIVE YEARS, 7TH APA FOMAT & SEE TEMPLATE ATTACHED

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.
  • 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.

The Assignment

Record yourself presenting the complex case study for your clinical patient. In your presentatio

Rubric Detail

Select Grid View or List View to change the rubric’s layout.

Content

Name: PRAC_6665_Week7_Assignment2_Rubric

  Excellent Good Fair Poor
Photo ID display and professional attire

Points:

Points Range:
5 (5%) – 5 (5%)

Photo ID is displayed. The student is dressed professionally.

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

Photo ID is not displayed. Student must remedy this before grade is posted. The student is not dressed professionally.

Feedback:
Time

Points:

Points Range:
5 (5%) – 5 (5%)

The video does not exceed the 8-minute time limit.

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

Feedback:

Points:

Points Range:
0 (0%) – 0 (0%)

The video exceeds the 8-minute time limit. (Note: Information presented after 8 minutes will not be evaluated for grade inclusion.)

Feedback:
Discuss Subjective data:

• Chief complaint

• History of present illness (HPI)

• Medications

• Psychotherapy or previous
psychiatric diagnosis

• Pertinent histories and/or ROS

Points:

Points Range:
9 (9%) – 10 (10%)

The video accurately and concisely presents the patient’s subje

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

© 2021 Walden University

Page 1 of 3

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 diagnostic criteria for each differential diagnosis and explain what DSM-5 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

!), 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 are not present from illnesses to dem

Assignment 2: Focused SOAP Note and Patient Case Presentation

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. 

To Prepare

Review the Kaltura Media Uploader resource for help creating your self-recorded Kaltura video

· 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.

· 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.

The Assignment

Record yourself presenting the complex case study for your clinical patient. In your presentation:

· Dress professionally and present yourself in a professional manner.

· Display your photo ID at the start of the video when you introduce yourself.

· Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).

· Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.

· Report normal diagnostic results as the name of the test and “normal” (rather than specific val

CASE STUDY

Subjective

Patient is 24-year-old AA female seen today via Telehealth with consent obtained. She reports that she has been going through stuffs and need specialist to address her mood issues. She continued that this mood issue days’ back to 2019 and she was put on Seroquel. However, she admits that because she was pregnant then, she did not go back to continue to get help. After birth according to her, she navigated through life barely until now. Presently, I have been going through stressful things and am beginning to get aggressive with people. I noticed that am verbally and physically abusive to people for little stuff or triggers.” I need help”. She gave a background history that she experienced traumatic life with stepfather children abuse sexually at age of 10. Growing up with no parents in my life affected me also. I had couple of medical and mental health hospitalization. In one of the admissions in psychiatric hospital, I was given Seroquel and I feel like i need to get back to that as it helps me with my mood and sleep. Currently, I hardly get 4 hours of sleep and sometimes I do not get any.

Assessment
Patient report that her mood issue dates to 2019 and she was put on Seroquel. However, she admits that because she was pregnant then, she did not go back to continue to get help. After birth according to her, she navigated through life barely until now. Presently, I have been going through stressful things and am beginning to get aggressive with people. I noticed that am verbally and physically abusive to people for little stuff or triggers.” I need help”. She gave a background history that she experienced traumatic life with stepfather children abuse sexually at age of 10. Growing up with no parents in my life affected me also. I had couple of medical and mental health hospitalization. In one of the admissions in psychiatric hospital, I was given Seroquel and I feel like i need to get back to that as it helps me with my mood and sleep. Currently, I hardly have up to 4 hours of sleep and sometimes I do not get any. The provider reviewed her chart and condition and believe she will benefit from Therapy and will resume Seroquel 50mg at bedtime. Educated her about her disease’s progression and medication side effects.

PHQ 9 score-18/27

Diagnoses (F31.9) Bipolar disorder, unspecified

Plan

Plan in 90 days is to decrease mood disorder

To call 911 feeling suicidal or homicidal

Take prescribed Seroquel 50mg

Educated her on medication side effects or interactions

Patient is refer to Psychotherapy

To follow up in 4 weeks.

MEDICATIONS

Quetiapine Fumarate (SEROquel) 50 MG 1 tablet by mouth daily at bedtime

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