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

Focused SOAP Note and Patient Case Presentation

For this Assignment, you will document information about a patient that you examined during the last 3 weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient. Be sure to incorporate any feedback you received on your Week 3 and Week 7 case presentations into this final presentation for the course. 

To Prepare

· Review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.

· Select a child or adolescent patient that you examined during the last 3 weeks who presented with a disorder for which you have not already created a Focused SOAP Note in Weeks 3 or 7. (For instance, if you selected a patient with anorexia nervosa in Week 7, you must choose a patient with another type of disorder for this week.)

· 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

Subjective

The patient is a 21-year-old African American female who was seen today for her initial evaluation via telehealth session with her consent obtained. The patient stated, “I’m seeking a psychiatrist because my primary care physician suggested for me to see a psychiatrist to help me with my anger issues”. She stated that she has not being diagnosed for any mental problem before and not on any medication. The patient stated that she gets angry very quickly, depressed, and very anxious, sometimes without any reason she would lash out on people. “I just had my birthday, and I went out for a dinner with my friends, and I had a good time”. “I hear voices, but not that type of crazy voices that tell you to do somethings”. “It is just from my inner thought, maybe thinking in my head and talking out loud to myself”. She said she just gets irritated here and there from some people. She denies suicidal or homicidal ideation or intent presently. She also denies delusional or hallucination presently.

Objective

The patient is alert and oriented x 4 to person, place, time, and the situation. The patient was seen today in the clinic for initial evaluation via telehealth. The patient appeared very clean and dressed neatly. She has normal eye contact with normal psychomotor activity. Her attention is intact and very cooperative. Her speech is normal, her thought process is goal-directed, and her thought contents are circumstantial. Perceptions, insight, and judgment are good, intact cognitive, and language is normal and appropriate. She has euthymic and euphoric moods, and the affect is congruent to her mood. Memory intact denies suicidal or homicidal ideation or intent. She denies delusions and hallucinations. The patient scored 15/27 on the PHQ scale.

Assessment

The patient reported doing good and working two jobs to support herself. She said that she works as a pharmacy technician Monday through Friday and works as a concierge on weekends. The patient stated that she grew up with both parents but now they are divorced. She now lives with her mother and her siblings. The patient stated that she is seeking a psychiatrist because her primary care physician suggested for her to see a psychiatrist to help her to manage her anger issues. She stated that she has not being diagnosed for any mental problem before and not on any medication. The patient stated that she gets angry very quickly, depressed, and very anxious, sometimes without any reason she would lash out on people. She said that her siblings get on her nerves sometimes and she gets irritated especially when they are together for so long. The patient stated that she completed high school and graduated. She said that she was never bullied, nor sexually assaulted. She said that she gets very anxious most of the time. The voices she hears are from her inner thought, and not that type of crazy voi

Rubric Detail

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Content

Name: PRAC_6665_Week9_Assignment2_Rubric

• Grid View
• List View

	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 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 Why work with us? Authenticity: All of our papers are authentic, as each paper of ours is composed according to your unique requirements. Confidentiality: We value you data. Our company is extremely efficient in guarding the privacy of our clients. 100% Money Back Guarantee: In the event you cancel your order, you get your money back as soon as possible, we give a 100% refund. 24/7 Support: Our team members are available via email, live chat, and phone. Revision Policy: You can apply for a revision if you think your paper could be better. In this case, your paper will be revised either by the specialist assigned to you or by another writer. How the Platform Works Click on 'Place Your Order' tab on the menu or click on 'Order Now' tab at the bottom and a new order page will appear Fill in your requirements depending on your needs under the 'PAPER DETAILS' area In the next section, fill in the academic level, required number of pages, paper deadline as provided in the drop-down menus. To enter your registration details, click on 'CREATE ACCOUNT & SIGN IN'. This step allows you to create an account with us for purposes of record-keeping. Click on 'PROCEED TO CHECK OUT' at the bottom of the page The next section requires you to fill in the payment details. Follow the guided process and soon your order will be available for our team to work on. Recent Posts Assess the part played by differing ideologies in the origins of the What was the significance or effects of the twin tower attack on Which of the following is not true about hitler’s theory of aryan How was beethovens music affected by the french revolution and The warp threds run the ? of the cloth. weft threds run ? the