In assessing patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders, you will continue the practice of looking to understand chief symptomology in order to develop a diagnosis. With a differential diagnosis in mind, you can then move to a treatment and follow-up plan that may involve both psychopharmacologic and psychotherapeutic approaches.
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
Rubric Detail
Select Grid View or List View to change the rubric’s layout.
Content
Name: NRNP_6675_Week3_Assignment_Rubric
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Excellent
90%–100% |
Good
80%–89% |
Fair
70%–79% |
Poor
0%–69% |
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Create documentation in the Focused SOAP Note Template about your assigned patient.
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 |
Points: Points Range: The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Feedback: |
Points: Points Range: The response accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Feedback: |
Points: Points Range: The response describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis but is somewhat vague or contains minor innacuracies. Feedback: |
Points: Points Range: The response provides an incomplete o 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 6675: PMHNP Care Across the Lifespan II 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 Case Study: Dev Cordoba © 2021 Walden University, LLC 1 Case Study: Dev Cordoba [MUSIC PLAYING] DR. JENNY: Hi there. My name is Dr. Jenny. Can you tell me your name and how old you are? DEV CORDOBA: My name is Dev, and I am seven years old. DR. JENNY: Wonderful. Dev, can you tell me what the month and the date is? And where are we right now? DEV CORDOBA: Today is St. Patrick’s Day. It’s March 17th. DR. JENNY: Do you know where we are? DEV CORDOBA: We’re at the school. DR. JENNY: Good. Did your mom tell you why you’re here today to see me? DEV CORDOBA: She thought you were going to help me be better. DR. JENNY: Yes, I am here to help you. Have you ever come to see someone like me before, or talked to someone like me before to help you with your mood? DEV CORDOBA: No, never. DR. JENNY: OK. Well, I would like to start with getting to know you a little bit better, if that’s OK. What do you like to do for fun when you’re at home? DEV CORDOBA: Oh, I have a dog. His name is Sparky. We play policeman in my room. And I have LEGOs, and I could build something if you want. DR. JENNY: I would love to see what you build with your LEGOs. Maybe you can bring that in for me next appointment. Who lives in your home? DEV CORDOBA: My mom and my baby brother and Sparky. DR. JENNY: Do you help your mom with your brother? DEV CORDOBA: No. His breath smells like bad milk all the time. [CHUCKLES] And he cries a lot, and my mom spends more time with him. DR. JENNY: So how do you feel most of the time? Do you feel sad or worried or mad or happy? DEV CORDOBA: Worried. DR. JENNY: What types of things do you worry about? Case Study: Dev Cordoba © 2021 Walden University, LLC 2 DEV CORDOBA: I don’t know, just everything. I don’t know. DR. JENNY: OK. So your mom tells me you also have a lot of bad dreams. Can you tell me a little more about your bad dreams, like maybe what they’re about, how many nights you might have them? DEV CORDOBA: I dream a lot that I’m lost, that I can’t find my mom or my little brother. They seem like they happen almost every night, but maybe not some nights. DR. JENNY: Now that must feel horrible. Have you ever been lost before when maybe you weren’t asleep? DEV CORDOBA: Oh, no. No. And I don’t like the dark. My mom puts me in a night light with the door open, so I know she’s really there. DR. JENNY: That seems like that probably would help. Do you like to go to school? Or would you rather not go? DEV CORDOBA: I worry about b PLEASE FOLLOW THE INSTRUCTIONS AS INDICATED BELOW: 1). ZERO (0) PLAGIARISM 2). AT LEAST 5 REFERENCES, NO MORE THAN 5 YEARS (WITHIN 5YRS, OR LESS THAN 5YRS) 3). PLEASE SEE THE ATTACHED RUBRIC DETAILS, the assignment, and instructions For Case Study Transcript, Focus soap Note Template, and focus Soap Note exemplar. 4). Please review and follow the grading rubric details and include each component in the assignment as required. Also, follow the APA 7 writing rules, style/Format, Title page, Introduction, Purpose statement, Literature Review, Conclusion, References. IMPORTANT!!! IMPORTANT!!! IMPORTANT!!! PLEASE TAKE NOTE below SAFE-ASSIGN and Plagiarism SAFE-ASSIGN HAS TO BE LOWER THAN 50%, AND IF IT’S HIGHER AND THERE IS EVIDENCE THAT PAST ASSIGNMENTS WERE REUSED FROM ANOTHER COURSE OR THERE ARE SIGNS OF PLAGIARISM, AN AI INVESTIGATION WILL BE OPEN.
Thank you very much for help. Week 9: Focused SOAP Note and Patient Case Student Name College of Nursing-PMHNP, Walden University NRNP 6675: PMHNP Care Across the Lifespan II Faculty Name Assignment Due Date
Week 9: Focused SOAP Note and Patient Case Subjective: CC (chief complaint): “I’m seeking a psychiatrist because my primary care physician suggested for me to see a psychiatrist to help me with my anger issues.” HPI: The patient is a 21-year-old African American female who was seen in the clinic for her initial evaluation via telehealth session with her consent obtained. The patient stated that she was seeking a psychiatrist because her primary care physician suggested for her to see a psychiatrist to help her with anger issues. She stated that she has not being diagnosed for any mental problem before and has never been on any medication before as well. The patient stated that she gets very angry, depressed, and anxious quickly; even she reported that sometimes she would lash out on people without any reason. She said that her siblings get on her nerves sometimes and she gets irritated especially when they are together for so a long period of time. She stated, “I just had my birthday, and I went out for a dinner with my friends, and I had a good time”. The patient reported, “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. Substance Current Use: None Family History: Maternal grandmother has depression and dementia. Psychosocial History: The patient stated that she grew up with both parents but now they are divorced. She now lives with her mother and her siblings. She 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. She completed high school and graduated. She has few friends and she is not in any relationship right now. She is not married and has no children. Medical History: None · Current Medications: None. · Allergies: NKDA · Reproductive Hx: Heterosexual. Currently not sexually active. No children. ROS: · GENERAL: Reports poor eating habits. Denies weakness, fatigue, fever, or chills. · HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, · Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat. · SKIN: No rash or itching. · CARDIO 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 6675: PMHNP Care Across the Lifespan II Faculty Name Assignment Due Date Introduction Information from a patient’s first appointment is used to plan each psychological intervention Refai et al (2018). Each patient’s treatment starts with a full health and mental health exam that includes talking openly and honestly about mental health, drug use, and the mental health history of their family. In this case, the patient’s test was written down, and the diagnostic idea was made based on what was learned from the patient during the trial. As the situation got worse, solutions were made. The patient, a 7 year old boy, was scheduled for a psychiatric exam after the pediatrician suggested he see a psychiatrist. At this time, the patient is not taking any medicine. The patient was initialy placed on DDAVP by his pediatrician which did not help. Subjective: CC: “My mother told me you will help me get better” HPI: R.C. is a 7-year-old boy who was referred to a psychiatrist for a checkup after his teacher tried unsuccessfully to help him with his mood. During the interview, the mother and patient stated that a pediatrician put her son on DDAVP, which did not help him. During the chat, the patient expresses that he occasionally feels anxious. “Most of the time I feel anxious, but I don’t know, just everything,” the patient explained. The patient also confesses to having nightmares. “I regularly dream about getting lost, I can’t find my mother or my small brother,” he stated, which is terrible. It appears that a dream occurs virtually every night, although perhaps not every night. The patient has a nightmare and cannot find his sibling or mother. When questioned if the patient is feeling disoriented. “When I’m alone,” the patient says, “I worry about my mother and brother.” “People at school don’t like me,” the patient continued. According to the patient’s mother, her classmates nicknamed her nasty things because she didn’t wash her hands. The patient expressed his displeasure with it. His mother never returned home. The patient claimed that his teacher was also spoiling him in class. His teacher instructed him to sit down and focus. The patient’s mother was also interviewed throughout the session. The mother voiced her concern that the patient was frightened and worried about silly things like dying, that her mother loved her brother more than him, and that she would not pick him up from school. The mother also mentioned that the patient’s father had been killed in combat, but that it was too soon to tell him because he was too young. My mother feels bad about not exposing Rev.’s fa 
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