Prac 6665 wk3 soap note

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SAMPLES  AND TEMPLATE INCLUDED

PRAC 6665 WK3 SOAP

Assignment 2: Focused SOAP Note and Patient Case Presentation

Photo Credit: Pexels

Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. 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 three 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 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 patient of any age (either a child or an adult) that you examined during the last 3 weeks.

· 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 diagnos

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

Week 3: Focused SOAP Note and Patient Case Presentation

College of Nursing-PMHNP, Walden University

NRNP 6665: PMHNP Care Across the Lifespan 1 Practicum

Introduction

Every patient’s treatment begins with a full health assessment, because the plan of care

and every mental intervention are all dependent on the information gathered at the initial meeting

with the patient. In this situation, the assessment was documented after the patient was evaluated,

and a diagnostic impression was formed based on the information gained from the patient during

This study source was downloaded by 100000822789681 from CourseHero.com on 03-15-2022 02:50:21 GMT -05:00

https://www.coursehero.com/file/112763331/Wk-3-Assgn-SOAPdocx/

the evaluation. A 30 years old White female attending a follow up on tele psych appointment.

Patient states that she is doing well with meds. Patient is taking all prescribed

medications: Gabapentin 100mg PO 3 times per day, Wellbutrin 300mg PO daily, Effexor 112mg

PO daily and will continue with the above listed medications as they are effective.

Subjective:

CC: “Sometimes I get really anxious, sometimes depressed. It’s hard to describe my feelings”.

HPI: Amy a 30 years old White female attending a follow up on tele psych appointment. Patient

states that she is doing well with meds. Patient is taking Gabapentin 100mg PO 3 times per day,

Wellbutrin 300mg PO daily, Effexor 112mg PO daily. Patient admits to the use of Weed and

Alcohol daily. Admits that she took alcohol last night and that has been going on for the last 10

days. States that weed makes her more social, calm, get things done. The patient was evaluated

by the Nurse Practitioner student. The patient describes her mood as good. Her affect is restricted

but adequate. Patient denies SI/HI. Following the note on prior meeting with patient and the

psychiatrist, patient is coping well with her mental condition.

Substance Current Use and History: Patient admit to use of alcohol and weed. Admits that she

took alcohol last night and that has been going on for the last 10 days. States that weed makes

her more social, calm, get things done.

This study source was downloaded by 100000822789681 from CourseHero.com on 03-15-2022 02:50:21 GMT -05:00

https://www.coursehero.com/file/112763331/Wk-3-Assgn-SOAPdocx/

https://www.coursehero.com/

Rubric Detail

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

Content

Name: PRAC_6665_Week3_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

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