• Select an adult patient that you examined during the last 4 weeks who presented with a disorder other than the disorder present in your Week 3 Case Presentation.
  • 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.

 

  • 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 diagnostic results as the name of the test and  “normal” (rather than specific value). Abnormal results should be  reported as a specific value.
  • Be succinct in your presentation, and do not exceed 8 minutes.  Specifically address the following for the patient, using your SOAP note  as a guide:
  • 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: What was your plan for psychotherapy? What was your  plan for treatment and management, including alternative therapies?  Include pharmacologic and nonpharmacologic treatments, alternative  therapies, and follow-up parameters, as well as a rationale for this  treatment and management plan. Be sure to include at least one health  promotion activity and one patient education strategy.
  • Reflection notes: What would you do differently with this  patient if you could conduct the session over? If you are able to follow  up with your patient, explain whether these interventions were  successful and why or why not. If you were not able to conduct a follow  up, discuss what your next intervention would be.

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): I’m still having sleep issues’

HPI: C. C. is a 66-year-old caucian male presents for medication management follow up for insomnia. He was initiated on Trazodone last appt which he says was effective for two weeks.

Past psychiatric history– Patient has history of ADHD and anxiety. ADHD was diagnosed t the age of 15 years and Anxiety about 2 years ago. Denies any history of hospitalization due to psychiatry illness.

Medication trials and current medications– Adderral XL 60mg in the morning and Adderral IR 30mg at 1pm for ADHD, Alprazolam 1mg daily for Anxiety and trazodone 50mg at night for insomnia. Newly added medication Temazepam 15mg at bedtime.

Psychotherapy or previous psychiatric diagnosis- No history previous psychotherapy or prior psychiatry hospitalization. During this visit, patient was educated on healthy living lifetyle

Pertinent substance use- Patient denies any substance use. Drinks 2 to 3 bottles of beer socially. Currently smokes 3 to 5 ticks of cigaretes per day

Family psychiatric/substance use. Patient was born in Elgin in 1955. No history of sexual abuse.No known substance abuse in the family. No known family psychiatry history

Social History- Patient lives alone in an apartment. Patient has 2 siblings who lives in another states. Patient’s best friend is G.A. they hange out once every week but has been every other week due to covid. Patient reported he takes about 30 minutes of brisk walk around the neighbourhood as a form of exercise. Patient enjoys spiritual

Allergies- No known allergies

Medical History: No medical history

· Current Medications: Adderral XR 60mg Qam, Adderral IR 30mg at noon for ADHD, Alprazolam 1mg Qday for anxiety, Temazepam 15mg at bedtime. Trazodone 50mg QHS rpn

· Reproductive Hx: Pt is divorced. Patient was previousl marrid for 20 years before getting a divorce. Patient has a girlfriend who he is sexually active with.

ROS:

Vitals: BP 117/82, P- 87,T-97.8, R- 16, Spo2-98% in room air

· GENERAL: No fever, chills, weakness, or fatigue and no weight loss

· · HEENT: Head is Normocephalic and atraumatic, Eye- pupils are equal, no discharges, No double, blurred vision. Ear, Nose, and Throat -No hearing loss, No congestion, no sore throat, and no sneezing

· · SKIN: Skin is warm, No rash or itching

· · CARDIOVASCULAR: No chest pain, N

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

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Week 3: (Mood disorder)

College of Nursing-PMHNP, Walden University

NRNP 6665: PMHNP Care Across the Lifespan I

Faculty Name

Assignment Due Date

Subjective:

CC (chief complaint): ‘I have history of taking medications and stopping them because thet squashes who I am’

HPI: P.P is a 25 years old female with history of bipolar and depression presented to the clinic for mental health assessment. Per patient report, patient has not been compliant with her medications because of the side effects she experienced from taking them which has led to the periods of hyperactivities, loss of sleep, anhedonia, impulsiveness, talkatiness and engaging in random sex with random individials. Patient reported her first episode and hospitalization was at the age of 16 and has had a total of 4 hospitalizations. Patient reported that she experiences depression about four times a year whePatient is in the office for possible medication changes.

Substance Current Use: Patient smokes a pack of cigarettes per day. Pt denies the use of other illicit drugs and Alcohol. The last time she had alcohol as reported by patient was at the age of 19.

Medical History:

· Current Medications: Levothyroxine ( dosage unknown) and birth control ( name and dosage unknown). Patient reported that prescribed Zoloft, risperidone and quetiapine in the past but she stopped taking them due to side effect and possible therapeutic effect which the patient was not comfortable with.

· Allergies: No known Allergies

· Reproductive Hx: Patient reported multiple sexual partners and engages in sex with random individual. Patient is oral contraceptives for polycystic ovaries. Never been married or pregnant. Last menstrual period was last month (date unknown).

ROS:

· GENERAL: No fever, chills, weakness, or fatigue and no weight loss

· · HEENT: Head is Normocephalic and atraumatic, Eye- pupils are equal, no discharges, No double, blurred vision. Ear, Nose, and Throat -No hearing loss, No congestion, no sore throat, and no sneezing

· · SKIN: Skin is warm, No rash or itching

· · CARDIOVASCULAR: No chest pain, No chest pressure, and no edema, No palpitation

· · RESPIRATORY: No respiratory distress.

· · GASTROINTESTINAL: No distension noted, No anorexia and vomiting

· · GENITOURINARY: No burning on urination

· · NEUROLOGICAL: The patient is alert and oriented, no dizziness, numbness, or tingling sensation of the extremities

· · MUSCULOSKELETAL: No muscle pain, No back pain, nobody stiffness, no edema noted

· · HEMATOLOGIC: The patient is not frail and no bleeding

· · LYMPHATICS: No enlarged lymph n