Wk3 assign1 nrnp 6675

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

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

Case Study: Dev Cordoba

© 2021 Walden University, LLC 1

Case Study: Dev Cordoba
Program Transcript

[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

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