Week (enter week #): (Enter assignment title)

Student Name

College of Nursing-PMHNP, Walden University

PRAC 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

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

Grand Rounds Discussion: Complex Case Study Presentation

In Weeks 4, 7, and 9 of the courses, you will participate in clinical discussions called grand rounds. In one of these three weeks, you will be a presenter as well as help facilitate the online discussion; in the others you will be an active discussion participant. When it is your week to present, you will create a Focused SOAP note and a short didactic (teaching) video presenting a real (but de-identified) complex patient case from your practicum experience.

You should have received an assignment from your instructor letting you know which week of the course you are assigned to present. 

To prepare: 

· Review this week’s Learning Resources and consider the insights they provide. Also 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/adolescent or adult patient from your clinical experience that presents with a significant concern. Create a focused SOAP note for this patient using the template in the Resources. All SOAP notes must be signed, and each page must be initialed by your Preceptor. When you submit your SOAP note, you should include the complete 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.
Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.

· Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice what you will say beforehand, and ensure that you have the appropriate lighting and equipment to record the presentation.

· Your presentation should include objectives for your audience, at least 3 possible discussion questions/prompts for your classmates to respond to, and at least 5 scholarly resources to support your diagnostic reasoning and treatment plan.

Video assignment for this week’s presenters:

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).

· State 3–4 objectives for the presentation that are targeted, clear, use appropriate verbs from Bloom’s taxonomy, and address what the audience will know or be able to do after viewing.

· Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, famil

My Patient Case Study:

Patient is a 44-year-old African American male seen today for an initial evaluation and treatment with consent obtained. Patent stated, ” I am struggling. I try to make things happen and stay on track. I am having hard time communicating with my family and my children, I feel paranoid and separated from everything. I know that this is not me, I need help to handle stress”. Patient reported that he was discharge from psychiatrist hospital six-month ago. And since then, he has not seen any provider. Patient reports feelings of irritability, anger, paranoia, and inability to handle pressure. Patient currently lives alone and rents a room in a house, has a small group friend. Patient is on disability, and is distanced from his children and extended family. Patient further stated both the mother and father side have some mental illness. He hopes to regain motivation, attentiveness, and confidence so he can develop a better relationship with his family. Patient is currently on Wellbutrin 150mg by mouth daily for depression which was prescribed by his PCP. Patient reported no changes his depressive mood despite the fact he has been on this medication for six months or more. Provider increased the Wellbutrin to 300mg by mouth daily and Hydroxyzine 25mg by mouth every 8hrs as needed for Anxiety. Patient was educated to take Wellbutrin 300mg daily in the morning to help decrease his depression and increase his overall drive to accomplish his goals of confidence, motivation, and attentiveness. Patient denies suicidal or homicidal ideation. Patient was educated to monitor side/adverse effect and drug interaction of the medication which he some verbalized understanding. Patient will be referred for psychotherapy sessions for education on anger and stress management. Patient is educated on positive coping mechanisms to improve his mood. Patient verbalizes understanding.

PHQ Score is 15/27

Vital Sign Temp-98.6, Res-20, Pulse-76, B/P-138/82, Weight-188lbs

Patient will continue Wellbutrin 300mg daily to decrease depressive mood and Hydroxyzine 25m as needed for Anxiety.

Patient will be educated on medication side effects and adverse effects

Patient to follow up with psychotherapy

Patient will be educated on positive coping mechanisms to improve mood

Follow up in 2 weeks

Call 911 if experiencing suicidal or homicidal ideations.

Rubric Detail

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Content

Name: PRAC_6675_Week4_Discussion_Presenter_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 with a lab coat. 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 with a lab coat. 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 the 8 minutes will not be evaluated for grade inclusion.) Feedback:
Objectives for the Presentation	Points: Points Range: 5 (5%) – 5 (5%) 3–4 objectives provided and written in terms of what the audience will know or be able to do after viewing. Appropriate Bloom’s verbs are used. Objectives are targeted an 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