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.
PATIENTS INFORMATION
S:15y/o female presents with chief complaint of increase excessive worry and lack of concentration for Psychiatry initial evaluation. Patient dealing with daily symptoms and requesting medical management to aid with symptoms.
Hx of mental health: Depression
Prescription Hx: Sertraline (Zoloft)
Symptoms: Irritability, difficulty falling and staying asleep, lack of concentration, restlessness or feeling on edge,
Triggers/stressors: unclear
Mood/Affect: Anxious
Suicidality: None reported
Substance Use: None reported
O: Insight and Judgement: No evidence of being outside normal limits
Thought Process: No evidence of being outside normal limits
A: Generalized anxiety, severe
P: Will prescribe medication to aid with anxiety symptoms. Prescribed Escitalopram 10mg PO daily. Selection based on patient’s presenting symptoms. F/U 1 month, or sooner if needed.
Patient was brought in for evaluation of worsening symptom, diagnosed with depression and anxiety at the age of 12 after the death of her father from car accident. She is in 10th grade, and experiencing increase worry that is affecting her academic performance and her participation in school game. Initially was as on Sertraline (Zolof) (dose unknown) and CBT, stopped Zoloft due to unpleasant side effect. Both parents had hx. of depression and anxiety, Pt have one sibling (elder brother 18 yrs). Pt is a member of basketball team in her school.
THE ASSIGNMENT
·
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 you
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 wi
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