Please see the attachments. 

SOAP NOTE Question/Assgn

Review the case study below:

1. Your presentation must include four objectives/goals for your audience.

1. At least 3 possible discussion questions/prompts for your classmates to respond to.

1. At least 5 scholarly resources to support your diagnostic reasoning and treatment plan.

1. . 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.

1. 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. 

1. Pose three questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.

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?

0. Objective: What observations did you make during the psychiatric assessment? 

0. Assessment: Discuss their 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 is supported by the patient’s symptoms.

0. Plan: What was your plan for psychotherapy (include one health promotion activity and patient education)? 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. 

0. Reflection notes: What would you do differently with this patient if you could conduct the session again? 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.

Case study

CC: I cannot stop being afraid of failing

The patient 18-year-old Hispanic female (in her last year of high school) with history of OCD, came to the clinic alone for medication management. The patient reports poor sleeping pattern, does not wake up rested, she finds herself sometimes hyperventilating when she faces difficulties with school exams and canno

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

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

© 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

Rubric Detail

 

Name: PRAC_6675_Week4_Discussion_Presenter_Rubric

·

Grid View

·
List View

 

Excellent

Good

Fair

Poor

0 (0%) – 0 (0%)

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.

0 (0%) – 0 (0%)

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.)

Objectives for the Presentation

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 and clear.

4 (4%) – 4 (4%)

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.

3.5 (3.5%) – 3.5 (3.5%)

At least 3 objectives provided and written in terms of what the audience will know or be able to do after viewing, but are somewhat vague or unclear. Appropriate Bloom’s verbs may be missing.

0 (0%) – 3 (3%)

Fewer than 3 objectives provided. Objectives for the presentation are vague, unclear, or missing.

Discuss subjective data:

• Chief complaint


• History of present illness (HPI)


• Medications


• Psychotherapy or previous psychiatric diagnosis


• Pertinent histories and/or ROS

5 (5%) – 5 (5%)

The video accurately and concisely presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis.

4 (4%) – 4 (4%)

The video accurately presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric di