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Focused SOAP Note and Patient Case Presentation

Focused SOAP Note and Patient Case Presentation

For this Assignment, you will document information about a patient that you examined during the last 3 weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient. Be sure to incorporate any feedback you received on your Week 3 and Week 7 case presentations into this final presentation for the course. 

To Prepare

· 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 or adolescent patient that you examined during the last 3 weeks who presented with a disorder for which you have not already created a Focused SOAP Note in Weeks 3 or 7. (For instance, if you selected a patient with anorexia nervosa in Week 7, you must choose a patient with another type of disorder for this week.)

· 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 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 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 supported by the patient’s symptoms.

· 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. 

· 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.

Focused SOAP Note and Patient Case Presentation

Subjective

The patient is a 21-year-old African American female who was seen today for her initial evaluation via telehealth session with her consent obtained. The patient stated, “I’m seeking a psychiatrist because my primary care physician suggested for me to see a psychiatrist to help me with my anger issues”. She stated that she has not being diagnosed for any mental problem before and not on any medication. The patient stated that she gets angry very quickly, depressed, and very anxious, sometimes without any reason she would lash out on people. “I just had my birthday, and I went out for a dinner with my friends, and I had a good time”. “I hear voices, but not that type of crazy voices that tell you to do somethings”. “It is just from my inner thought, maybe thinking in my head and talking out loud to myself”. She said she just gets irritated here and there from some people. She denies suicidal or homicidal ideation or intent presently. She also denies delusional or hallucination presently.

Objective

The patient is alert and oriented x 4 to person, place, time, and the situation. The patient was seen today in the clinic for initial evaluation via telehealth. The patient appeared very clean and dressed neatly. She has normal eye contact with normal psychomotor activity. Her attention is intact and very cooperative. Her speech is normal, her thought process is goal-directed, and her thought contents are circumstantial. Perceptions, insight, and judgment are good, intact cognitive, and language is normal and appropriate. She has euthymic and euphoric moods, and the affect is congruent to her mood. Memory intact denies suicidal or homicidal ideation or intent. She denies delusions and hallucinations. The patient scored 15/27 on the PHQ scale.

Assessment

The patient reported doing good and working two jobs to support herself. She said that she works as a pharmacy technician Monday through Friday and works as a concierge on weekends. The patient stated that she grew up with both parents but now they are divorced. She now lives with her mother and her siblings. The patient stated that she is seeking a psychiatrist because her primary care physician suggested for her to see a psychiatrist to help her to manage her anger issues. She stated that she has not being diagnosed for any mental problem before and not on any medication. The patient stated that she gets angry very quickly, depressed, and very anxious, sometimes without any reason she would lash out on people. She said that her siblings get on her nerves sometimes and she gets irritated especially when they are together for so long. The patient stated that she completed high school and graduated. She said that she was never bullied, nor sexually assaulted. She said that she gets very anxious most of the time. The voices she hears are from her inner thought, and not that type of crazy voices that tells you to do something. She stated that she has a poor eating habit and that she overeats most of the time. She said that she sleeps about 6 hours a day. She stated that she used to be sexually active but not in any relationship now. She said she is not married and has no children. She has few friends. The patient stated that the grandmother on her mother’s side has depression, and now she is having dementia as she is getting older. She said she verbally lashes at people sometimes for no reason. Upon assessment, her PHQ-9 scale score is 15/27. She stated that she weighs 200lbs and her height is 5’4’’. Upon assessment, the patient is diagnosed with schizoaffective disorder and anxiety disorder. The patient is not on any medication presently. The patient is referred to a psychotherapist and will be scheduled to see a therapist weekly. The patient is encouraged to engage in exercise to build up her serotonin. She is also encouraged to be taking deep breathing, not eat after 7 pm, and keep electronics away at bedtime. Also, she encouraged to keep a journal of her daily activities and will review it next appointment in 4 weeks. She is encouraged to call a suicide hotline or call 911 or call the psychiatrist’s office when wants to talk. She verbalized understanding.

Plan of care:

The patient will have decreased feelings of depression and anxiety over the next 90 days.

The patient is educated on the use of positive coping skills like exercising, deep breathing, and journaling daily.

The patient is referred to a psychotherapist weekly.

Follow up in 4 weeks on 5/17/22.

Call 911 for suicidal or homicidal ideation.

“I just had my birthday, and I went out for diner with my friends, and I had a good time”.

Focused SOAP Note and Patient Case Presentation

Rubric Detail

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

Content

Name: PRAC_6665_Week9_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 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.

Feedback:

Points:

Points Range:
8 (8%) – 8 (8%)

The video accurately 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.

Feedback:

Points:

Points Range:
7 (7%) – 7 (7%)

The video 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, but is somewhat vague or contains minor inaccuracies.

Feedback:

Points:

Points Range:
0 (0%) – 6 (6%)

The video presents an incomplete, inaccurate, or unnecessarily detailed/verbose description of 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. Or subjective documentation is missing.

Feedback:

Discuss Objective data:

• 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

Points:

Points Range:
9 (9%) – 10 (10%)

The video accurately and concisely documents the patient’s physical exam for pertinent systems. Pertinent diagnostic tests and their results are documented, as applicable.

Feedback:

Points:

Points Range:
8 (8%) – 8 (8%)

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are documented, as applicable.

Feedback:

Points:

Points Range:
7 (7%) – 7 (7%)

Documentation of the patient’s physical exam is somewhat vague or contains minor inaccuracies. Diagnostic tests and their results are documented but contain inaccuracies.

Feedback:

Points:

Points Range:
0 (0%) – 6 (6%)

The response provides incomplete, inaccurate, or unnecessarily detailed/verbose documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or objective documentation is missing.

Feedback:

Discuss results of Assessment:

• Results of the mental status examination

• Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. 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.

Points:

Points Range:
18 (18%) – 20 (20%)

The video accurately documents the results of the mental status exam.

Video presents at least three differentials in order of priority for a differential diagnosis of the patient, and a rationale for their selection. Response justifies the primary diagnosis and how it aligns with DSM-5 criteria.

Feedback:

Points:

Points Range:
16 (16%) – 17 (17%)

The video adequately documents the results of the mental status exam.

Video presents three differentials for the patient and a rationale for their selection. Response adequately justifies the primary diagnosis and how it aligns with DSM-5 criteria.

Feedback:

Points:

Points Range:
14 (14%) – 15 (15%)

The video presents the results of the mental status exam, with some vagueness or inaccuracy.

Video presents three differentials for the patient and a rationale for their selection. Response somewhat vaguely justifies the primary diagnosis and how it aligns with DSM-5 criteria.

Feedback:

Points:

Points Range:
0 (0%) – 13 (13%)

The response provides an incomplete, inaccurate, or unnecessarily detailed/verbose description of the results of the mental status exam and explanation of the differential diagnoses. Or assessment documentation is missing.

Feedback:

Discuss treatment Plan:

• A treatment plan for the patient that addresses psychotherapy; one health promotion activity and one patient education strategy; plan for treatment and management, including alternative therapies; pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters; and a rationale for the approaches selected.

Points:

Points Range:
18 (18%) – 20 (20%)

The video clearly and concisely outlines an evidence-based treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear and concise rationale for the treatment approaches recommended is provided.

Feedback:

Points:

Points Range:
16 (16%) – 17 (17%)

The video clearly outlines an appropriate treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear rationale for the treatment approaches recommended is provided.

Feedback:

Points:

Points Range:
14 (14%) – 15 (15%)

The response somewhat vaguely or inaccurately outlines a treatment plan for the patient and provides a rationale for the treatment approaches recommended.

Feedback:

Points:

Points Range:
0 (0%) – 13 (13%)

The response does not address the diagnosis or is missing elements of the treatment plan.

Feedback:

Reflect on this case. Discuss what you learned and what you might do differently.

Points:

Points Range:
5 (5%) – 5 (5%)

Reflections are thorough, thoughtful, and demonstrate critical thinking.

Feedback:

Points:

Points Range:
4 (4%) – 4 (4%)

Reflections demonstrate critical thinking.

Feedback:

Points:

Points Range:
3.5 (3.5%) – 3.5 (3.5%)

Reflections are somewhat general or do not demonstrate critical thinking.

Feedback:

Points:

Points Range:
0 (0%) – 3 (3%)

Reflections are incomplete, inaccurate, or missing.

Feedback:

Focused SOAP Note documentation

Points:

Points Range:
18 (18%) – 20 (20%)

The response clearly, accurately, and thoroughly follows the Focused SOAP Note format to document the selected patient case.

Feedback:

Points:

Points Range:
16 (16%) – 17 (17%)

The response accurately follows the Focused SOAP Note format to document the selected patient case.

Feedback:

Points:

Points Range:
14 (14%) – 15 (15%)

The response follows the Focused SOAP Note format to document the selected patient case, with some vagueness and inaccuracy.

Feedback:

Points:

Points Range:
0 (0%) – 13 (13%)

The response incompletely and inaccurately follows the Focused SOAP Note format to document the selected patient case.

Feedback:

Presentation style

Points:

Points Range:
5 (5%) – 5 (5%)

Presentation style is exceptionally clear, professional, and focused.

Feedback:

Points:

Points Range:
4 (4%) – 4 (4%)

Presentation style is clear, professional, and focused.

Feedback:

Points:

Points Range:
3.5 (3.5%) – 3.5 (3.5%)

Presentation style is mostly clear, professional, and focused

Feedback:

Points:

Points Range:
0 (0%) – 3 (3%)

Presentation style is unclear, unprofessional, and/or unfocused.

Feedback:

Show Descriptions

Show Feedback

Photo ID display and professional attire–

Levels of Achievement:

Excellent
5 (5%) – 5 (5%)

Photo ID is displayed. The student is dressed professionally.

Good
0 (0%) – 0 (0%)

 

Fair
0 (0%) – 0 (0%)

 

Poor
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–

Levels of Achievement:

Excellent
5 (5%) – 5 (5%)

The video does not exceed the 8-minute time limit.

Good
0 (0%) – 0 (0%)

 

Fair
0 (0%) – 0 (0%)

 

Poor
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

Levels of Achievement:

Excellent
9 (9%) – 10 (10%)

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.

Good
8 (8%) – 8 (8%)

The video accurately 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.

Fair
7 (7%) – 7 (7%)

The video 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, but is somewhat vague or contains minor inaccuracies.

Poor
0 (0%) – 6 (6%)

The video presents an incomplete, inaccurate, or unnecessarily detailed/verbose description of 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. Or subjective documentation is missing.

Feedback:

Discuss Objective data:

• 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–

Levels of Achievement:

Excellent
9 (9%) – 10 (10%)

The video accurately and concisely documents the patient’s physical exam for pertinent systems. Pertinent diagnostic tests and their results are documented, as applicable.

Good
8 (8%) – 8 (8%)

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are documented, as applicable.

Fair
7 (7%) – 7 (7%)

Documentation of the patient’s physical exam is somewhat vague or contains minor inaccuracies. Diagnostic tests and their results are documented but contain inaccuracies.

Poor
0 (0%) – 6 (6%)

The response provides incomplete, inaccurate, or unnecessarily detailed/verbose documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or objective documentation is missing.

Feedback:

Discuss results of Assessment:

• Results of the mental status examination

• Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. 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.–

Levels of Achievement:

Excellent
18 (18%) – 20 (20%)

The video accurately documents the results of the mental status exam.

Video presents at least three differentials in order of priority for a differential diagnosis of the patient, and a rationale for their selection. Response justifies the primary diagnosis and how it aligns with DSM-5 criteria.

Good
16 (16%) – 17 (17%)

The video adequately documents the results of the mental status exam.

Video presents three differentials for the patient and a rationale for their selection. Response adequately justifies the primary diagnosis and how it aligns with DSM-5 criteria.

Fair
14 (14%) – 15 (15%)

The video presents the results of the mental status exam, with some vagueness or inaccuracy.

Video presents three differentials for the patient and a rationale for their selection. Response somewhat vaguely justifies the primary diagnosis and how it aligns with DSM-5 criteria.

Poor
0 (0%) – 13 (13%)

The response provides an incomplete, inaccurate, or unnecessarily detailed/verbose description of the results of the mental status exam and explanation of the differential diagnoses. Or assessment documentation is missing.

Feedback:

Discuss treatment Plan:

• A treatment plan for the patient that addresses psychotherapy; one health promotion activity and one patient education strategy; plan for treatment and management, including alternative therapies; pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters; and a rationale for the approaches selected.–

Levels of Achievement:

Excellent
18 (18%) – 20 (20%)

The video clearly and concisely outlines an evidence-based treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear and concise rationale for the treatment approaches recommended is provided.

Good
16 (16%) – 17 (17%)

The video clearly outlines an appropriate treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear rationale for the treatment approaches recommended is provided.

Fair
14 (14%) – 15 (15%)

The response somewhat vaguely or inaccurately outlines a treatment plan for the patient and provides a rationale for the treatment approaches recommended.

Poor
0 (0%) – 13 (13%)

The response does not address the diagnosis or is missing elements of the treatment plan.

Feedback:

Reflect on this case. Discuss what you learned and what you might do differently.–

Levels of Achievement:

Excellent
5 (5%) – 5 (5%)

Reflections are thorough, thoughtful, and demonstrate critical thinking.

Good
4 (4%) – 4 (4%)

Reflections demonstrate critical thinking.

Fair
3.5 (3.5%) – 3.5 (3.5%)

Reflections are somewhat general or do not demonstrate critical thinking.

Poor
0 (0%) – 3 (3%)

Reflections are incomplete, inaccurate, or missing.

Feedback:

Focused SOAP Note documentation–

Levels of Achievement:

Excellent
18 (18%) – 20 (20%)

The response clearly, accurately, and thoroughly follows the Focused SOAP Note format to document the selected patient case.

Good
16 (16%) – 17 (17%)

The response accurately follows the Focused SOAP Note format to document the selected patient case.

Fair
14 (14%) – 15 (15%)

The response follows the Focused SOAP Note format to document the selected patient case, with some vagueness and inaccuracy.

Poor
0 (0%) – 13 (13%)

The response incompletely and inaccurately follows the Focused SOAP Note format to document the selected patient case.

Feedback:

Presentation style–

Levels of Achievement:

Excellent
5 (5%) – 5 (5%)

Presentation style is exceptionally clear, professional, and focused.

Good
4 (4%) – 4 (4%)

Presentation style is clear, professional, and focused.

Fair
3.5 (3.5%) – 3.5 (3.5%)

Presentation style is mostly clear, professional, and focused

Poor
0 (0%) – 3 (3%)

Presentation style is unclear, unprofessional, and/or unfocused.

Feedback:

Total Points: 100

Name: PRAC_6665_Week9_Assignment2_Rubric

Focused SOAP Note and Patient Case Presentation

PLEASE FOLLOW THE INSTRUCTIONS AS INDICATED BELOW:

1). ZERO (0) PLAGIARISM.

2). AT LEAST 5 REFERENCES, NO MORE THAN 5 YEARS (WITHIN 5YRS, OR LESS THAN 5YRS)

3). PLEASE SEE THE ATTACHED: Rubric details, Assignment details/Instructions, Focused SOAP Note Template.

4). Please review and follow the grading rubric details, and include each component in the assignment as required. Also, follow the APA 7 writing rules and style/Format.

Thank you.  

Focused SOAP Note and Patient Case Presentation

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

Focused SOAP Note and Patient Case Presentation

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 demonstrate you have indeed assessed for illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)

EXEMPLAR BEGINS HERE

Subjective:

CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:

N.M. is a 34-year-old Asian male presents for medication management follow up for anxiety. He was initiated sertraline last appt which he finds was effective for two weeks then symptoms began to return.

Or

P.H., a 16-year-old Hispanic female, presents for follow up to discuss previous psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications as we deferred until further testing and screening was conducted.

Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.

Paint a picture of what is wrong with the patient. First what is bringing the patient to your follow up evaluation? Document symptom onset, duration, frequency, severity, and impact. What has worsened or improved since last appointment? What stressors are they facing? Your description here will guide your differential diagnoses into your diagnostic impression. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns

ROS: Cover all body systems that may help you include or rule out a differential diagnosis. Please note: THIS IS DIFFERENT from a physical examination!

You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Objective:

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

Assessment:

Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.

He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking.   He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good. 


Diagnostic Impression: You must begin to narrow your differential diagnosis to your diagnostic impression. You must explain how and why (your rationale) you ruled out any of your differential diagnoses. You must explain how and why (your rationale) you concluded to your diagnostic impression. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection a discussion related to legal/ethical considerations (demonstrating 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.).



Case Formulation and Treatment Plan 

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions including psychotherapy and/or psychopharmacology, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. *See an example below. You will modify to your practice so there may be information excluded/included. If you are completing this for a practicum, what does your preceptor document?

Risks and benefits of medications are discussed including non- treatment. Potential side effects of medications discussed (be detailed in what side effects discussed). Informed client not to stop medication abruptly without discussing with providers. Instructed to call and report any adverse reactions. Discussed risk of medication with pregnancy/fetus, encouraged birth control, discussed if does become pregnant to inform provider as soon as possible. Discussed how some medications might decreased birth control pill, would need back up method (exclude for males).

Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. Discussed how drugs/alcohol affect mental health, physical health, sleep architecture.

Initiation of (list out any medication and why prescribed, any therapy services or referrals to specialist):

Client was encouraged to continue with case management and/or therapy services (if not provided by you)

Client has emergency numbers: Emergency Services 911, the Client’s Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)

Reviewed hospital records/therapist records for collaborative information; Reviewed PMP report (only if actually completed)

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (this relates to informed consent; you will need to assess their understanding and agreement)

Follow up with PCP as needed and/or for:

Labs ordered and/or reviewed (write out what diagnostic test ordered, rationale for ordering, and if discussed fasting/non fasting or other patient education)

Return to clinic:

Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care.



References (move to begin on next page)

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

© 2021 Walden University Page 1 of 3

Focused SOAP Note And Patient Case Presentation

The DSM-5 is a diagnostic tool. It has evolved over the decades, as have the classifications and criteria within its pages. It is used not just for diagnosis, however, but also for billing, access to services, and legal cases. Not all practitioners are in agreement with the content and structure of the DSM-5, and dissociative disorders are one such area. These disorders can be difficult to distinguish and diagnose. There is also controversy in the field over the legitimacy of certain dissociative disorders, such as dissociative identity disorder, which was formerly called multiple personality disorder. 

Focused SOAP Note and Patient Case Presentation

PLEASE FOLLOW THE INSTRUCTIONS AS INDICATED BELOW:

1). ZERO (0) PLAGIARISM

2). AT LEAST 5 REFERENCES, NO MORE THAN 5 YEARS (WITHIN 5YRS, OR LESS THAN 5YRS)

3). PLEASE SEE THE ATTACHED RUBRIC DETAILS,

Focused SOAP Note and Patient Case Presentation

Focused SOAP Note and Patient Case Presentation

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 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 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 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. Also 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 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.

Focused SOAP Note and Patient Case Presentation

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

Focused SOAP Note and Patient Case Presentation

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 demonstrate you have indeed assessed for illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)

EXEMPLAR BEGINS HERE

Subjective:

CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:

N.M. is a 34-year-old Asian male presents for medication management follow up for anxiety. He was initiated sertraline last appt which he finds was effective for two weeks then symptoms began to return.

Or

P.H., a 16-year-old Hispanic female, presents for follow up to discuss previous psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications as we deferred until further testing and screening was conducted.

Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.

Paint a picture of what is wrong with the patient. First what is bringing the patient to your follow up evaluation? Document symptom onset, duration, frequency, severity, and impact. What has worsened or improved since last appointment? What stressors are they facing? Your description here will guide your differential diagnoses into your diagnostic impression. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns

ROS: Cover all body systems that may help you include or rule out a differential diagnosis. Please note: THIS IS DIFFERENT from a physical examination!

You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Objective:

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

Assessment:

Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.

He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking.   He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good. 


Diagnostic Impression: You must begin to narrow your differential diagnosis to your diagnostic impression. You must explain how and why (your rationale) you ruled out any of your differential diagnoses. You must explain how and why (your rationale) you concluded to your diagnostic impression. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection a discussion related to legal/ethical considerations (demonstrating 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.).



Case Formulation and Treatment Plan 

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions including psychotherapy and/or psychopharmacology, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. *See an example below. You will modify to your practice so there may be information excluded/included. If you are completing this for a practicum, what does your preceptor document?

Risks and benefits of medications are discussed including non- treatment. Potential side effects of medications discussed (be detailed in what side effects discussed). Informed client not to stop medication abruptly without discussing with providers. Instructed to call and report any adverse reactions. Discussed risk of medication with pregnancy/fetus, encouraged birth control, discussed if does become pregnant to inform provider as soon as possible. Discussed how some medications might decreased birth control pill, would need back up method (exclude for males).

Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. Discussed how drugs/alcohol affect mental health, physical health, sleep architecture.

Initiation of (list out any medication and why prescribed, any therapy services or referrals to specialist):

Client was encouraged to continue with case management and/or therapy services (if not provided by you)

Client has emergency numbers: Emergency Services 911, the Client’s Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)

Reviewed hospital records/therapist records for collaborative information; Reviewed PMP report (only if actually completed)

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (this relates to informed consent; you will need to assess their understanding and agreement)

Follow up with PCP as needed and/or for:

Labs ordered and/or reviewed (write out what diagnostic test ordered, rationale for ordering, and if discussed fasting/non fasting or other patient education)

Return to clinic:

Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care.



References (move to begin on next page)

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

© 2021 Walden University Page 1 of 3

Focused SOAP Note And Patient Case Presentation

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. 

Focused SOAP Note and Patient Case Presentation

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 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.

Feedback:

Points:

Points Range:
8 (8%) – 8 (8%)

The video accurately 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.

Feedback:

Points:

Points Range:
7 (7%) – 7 (7%)

The video 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, but is somewhat vague or contains minor inaccuracies.

Feedback:

Points:

Points Range:
0 (0%) – 6 (6%)

The video presents an incomplete, inaccurate, or unnecessarily detailed/verbose description of 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. Or subjective documentation is missing.

Feedback:

Discuss Objective data:

• 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

Points:

Points Range:
9 (9%) – 10 (10%)

The video accurately and concisely documents the patient’s physical exam for pertinent systems. Pertinent diagnostic tests and their results are documented, as applicable.

Feedback:

Points:

Points Range:
8 (8%) – 8 (8%)

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are documented, as applicable.

Feedback:

Points:

Points Range:
7 (7%) – 7 (7%)

Documentation of the patient’s physical exam is somewhat vague or contains minor inaccuracies. Diagnostic tests and their results are documented but contain inaccuracies.

Feedback:

Points:

Points Range:
0 (0%) – 6 (6%)

The response provides incomplete, inaccurate, or unnecessarily detailed/verbose documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or objective documentation is missing.

Feedback:

Discuss results of Assessment:

• Results of the mental status examination

• Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. 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.

Points:

Points Range:
18 (18%) – 20 (20%)

The video accurately documents the results of the mental status exam.

Video presents at least three differentials in order of priority for a differential diagnosis of the patient, and a rationale for their selection. Response justifies the primary diagnosis and how it aligns with DSM-5 criteria.

Feedback:

Points:

Points Range:
16 (16%) – 17 (17%)

The video adequately documents the results of the mental status exam.

Video presents three differentials for the patient and a rationale for their selection. Response adequately justifies the primary diagnosis and how it aligns with DSM-5 criteria.

Feedback:

Points:

Points Range:
14 (14%) – 15 (15%)

The video presents the results of the mental status exam, with some vagueness or inaccuracy.

Video presents three differentials for the patient and a rationale for their selection. Response somewhat vaguely justifies the primary diagnosis and how it aligns with DSM-5 criteria.

Feedback:

Points:

Points Range:
0 (0%) – 13 (13%)

The response provides an incomplete, inaccurate, or unnecessarily detailed/verbose description of the results of the mental status exam and explanation of the differential diagnoses. Or assessment documentation is missing.

Feedback:

Discuss treatment Plan:

• A treatment plan for the patient that addresses psychotherapy; one health promotion activity and one patient education strategy; plan for treatment and management, including alternative therapies; pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters; and a rationale for the approaches selected.

Points:

Points Range:
18 (18%) – 20 (20%)

The video clearly and concisely outlines an evidence-based treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear and concise rationale for the treatment approaches recommended is provided.

Feedback:

Points:

Points Range:
16 (16%) – 17 (17%)

The video clearly outlines an appropriate treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear rationale for the treatment approaches recommended is provided.

Feedback:

Points:

Points Range:
14 (14%) – 15 (15%)

The response somewhat vaguely or inaccurately outlines a treatment plan for the patient and provides a rationale for the treatment approaches recommended.

Feedback:

Points:

Points Range:
0 (0%) – 13 (13%)

The response does not address the diagnosis or is missing elements of the treatment plan.

Feedback:

Reflect on this case. Discuss what you learned and what you might do differently.

Points:

Points Range:
5 (5%) – 5 (5%)

Reflections are thorough, thoughtful, and demonstrate critical thinking.

Feedback:

Points:

Points Range:
4 (4%) – 4 (4%)

Reflections demonstrate critical thinking.

Feedback:

Points:

Points Range:
3.5 (3.5%) – 3.5 (3.5%)

Reflections are somewhat general or do not demonstrate critical thinking.

Feedback:

Points:

Points Range:
0 (0%) – 3 (3%)

Reflections are incomplete, inaccurate, or missing.

Feedback:

Focused SOAP Note documentation

Points:

Points Range:
18 (18%) – 20 (20%)

The response clearly, accurately, and thoroughly follows the Focused SOAP Note format to document the selected patient case.

Feedback:

Points:

Points Range:
16 (16%) – 17 (17%)

The response accurately follows the Focused SOAP Note format to document the selected patient case.

Feedback:

Points:

Points Range:
14 (14%) – 15 (15%)

The response follows the Focused SOAP Note format to document the selected patient case, with some vagueness and inaccuracy.

Feedback:

Points:

Points Range:
0 (0%) – 13 (13%)

The response incompletely and inaccurately follows the Focused SOAP Note format to document the selected patient case.

Feedback:

Presentation style

Points:

Points Range:
5 (5%) – 5 (5%)

Presentation style is exceptionally clear, professional, and focused.

Feedback:

Points:

Points Range:
4 (4%) – 4 (4%)

Presentation style is clear, professional, and focused.

Feedback:

Points:

Points Range:
3.5 (3.5%) – 3.5 (3.5%)

Presentation style is mostly clear, professional, and focused

Feedback:

Points:

Points Range:
0 (0%) – 3 (3%)

Presentation style is unclear, unprofessional, and/or unfocused.

Feedback:

Show Descriptions

Show Feedback

Photo ID display and professional attire–

Levels of Achievement:

Excellent
5 (5%) – 5 (5%)

Photo ID is displayed. The student is dressed professionally.

Good
0 (0%) – 0 (0%)

 

Fair
0 (0%) – 0 (0%)

 

Poor
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–

Levels of Achievement:

Excellent
5 (5%) – 5 (5%)

The video does not exceed the 8-minute time limit.

Good
0 (0%) – 0 (0%)

 

Fair
0 (0%) – 0 (0%)

 

Poor
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

Levels of Achievement:

Excellent
9 (9%) – 10 (10%)

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.

Good
8 (8%) – 8 (8%)

The video accurately 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.

Fair
7 (7%) – 7 (7%)

The video 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, but is somewhat vague or contains minor inaccuracies.

Poor
0 (0%) – 6 (6%)

The video presents an incomplete, inaccurate, or unnecessarily detailed/verbose description of 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. Or subjective documentation is missing.

Feedback:

Discuss Objective data:

• 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–

Levels of Achievement:

Excellent
9 (9%) – 10 (10%)

The video accurately and concisely documents the patient’s physical exam for pertinent systems. Pertinent diagnostic tests and their results are documented, as applicable.

Good
8 (8%) – 8 (8%)

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are documented, as applicable.

Fair
7 (7%) – 7 (7%)

Documentation of the patient’s physical exam is somewhat vague or contains minor inaccuracies. Diagnostic tests and their results are documented but contain inaccuracies.

Poor
0 (0%) – 6 (6%)

The response provides incomplete, inaccurate, or unnecessarily detailed/verbose documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or objective documentation is missing.

Feedback:

Discuss results of Assessment:

• Results of the mental status examination

• Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. 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.–

Levels of Achievement:

Excellent
18 (18%) – 20 (20%)

The video accurately documents the results of the mental status exam.

Video presents at least three differentials in order of priority for a differential diagnosis of the patient, and a rationale for their selection. Response justifies the primary diagnosis and how it aligns with DSM-5 criteria.

Good
16 (16%) – 17 (17%)

The video adequately documents the results of the mental status exam.

Video presents three differentials for the patient and a rationale for their selection. Response adequately justifies the primary diagnosis and how it aligns with DSM-5 criteria.

Fair
14 (14%) – 15 (15%)

The video presents the results of the mental status exam, with some vagueness or inaccuracy.

Video presents three differentials for the patient and a rationale for their selection. Response somewhat vaguely justifies the primary diagnosis and how it aligns with DSM-5 criteria.

Poor
0 (0%) – 13 (13%)

The response provides an incomplete, inaccurate, or unnecessarily detailed/verbose description of the results of the mental status exam and explanation of the differential diagnoses. Or assessment documentation is missing.

Feedback:

Discuss treatment Plan:

• A treatment plan for the patient that addresses psychotherapy; one health promotion activity and one patient education strategy; plan for treatment and management, including alternative therapies; pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters; and a rationale for the approaches selected.–

Levels of Achievement:

Excellent
18 (18%) – 20 (20%)

The video clearly and concisely outlines an evidence-based treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear and concise rationale for the treatment approaches recommended is provided.

Good
16 (16%) – 17 (17%)

The video clearly outlines an appropriate treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear rationale for the treatment approaches recommended is provided.

Fair
14 (14%) – 15 (15%)

The response somewhat vaguely or inaccurately outlines a treatment plan for the patient and provides a rationale for the treatment approaches recommended.

Poor
0 (0%) – 13 (13%)

The response does not address the diagnosis or is missing elements of the treatment plan.

Feedback:

Reflect on this case. Discuss what you learned and what you might do differently.–

Levels of Achievement:

Excellent
5 (5%) – 5 (5%)

Reflections are thorough, thoughtful, and demonstrate critical thinking.

Good
4 (4%) – 4 (4%)

Reflections demonstrate critical thinking.

Fair
3.5 (3.5%) – 3.5 (3.5%)

Reflections are somewhat general or do not demonstrate critical thinking.

Poor
0 (0%) – 3 (3%)

Reflections are incomplete, inaccurate, or missing.

Feedback:

Focused SOAP Note documentation–

Levels of Achievement:

Excellent
18 (18%) – 20 (20%)

The response clearly, accurately, and thoroughly follows the Focused SOAP Note format to document the selected patient case.

Good
16 (16%) – 17 (17%)

The response accurately follows the Focused SOAP Note format to document the selected patient case.

Fair
14 (14%) – 15 (15%)

The response follows the Focused SOAP Note format to document the selected patient case, with some vagueness and inaccuracy.

Poor
0 (0%) – 13 (13%)

The response incompletely and inaccurately follows the Focused SOAP Note format to document the selected patient case.

Feedback:

Presentation style–

Levels of Achievement:

Excellent
5 (5%) – 5 (5%)

Presentation style is exceptionally clear, professional, and focused.

Good
4 (4%) – 4 (4%)

Presentation style is clear, professional, and focused.

Fair
3.5 (3.5%) – 3.5 (3.5%)

Presentation style is mostly clear, professional, and focused

Poor
0 (0%) – 3 (3%)

Presentation style is unclear, unprofessional, and/or unfocused.

Feedback:

Total Points: 100

Name: PRAC_6665_Week3_Assignment2_Rubric

Focused SOAP Note and Patient Case Presentation

The Patient Evaluation Information

Objective:

The patient is alert and oriented x 4, to person, place, time, and his situation. He was seen today for an initial evaluation via telehealth with his consent obtained. The patient appearance is clean and very neat. His mood is euthymic, and affect is congruent to his mood. His thought process is logical, and goal directed. She has good judgement and insight. She denies suicidal or homicidal ideations currently. She denies visual but report auditory hallucinations currently

General Appearance: Neat & clean.

Eye contact: Normal.

Psychomotor Activity: Normal.

Orientation: Person. Place. Time. Situation.

Attention: Intact.

           

BEHAVIOR: Cooperative.

SPEECH: Normal.

MOOD: Euthymic. Euphoric.

AFFECT: Appropriate.

THOUGHT PROCESS: Goal Directed, Logical.

THOUGHT CONTENT: Intact.

PERCEPTIONS: Good.

INSIGHT: Good.

JUDGMENT: Good.

COGNITION: Intact.

Language. WNL. Abnormal

MEMORY: None. Immediate. Recent. Remote.

C-SSRS (CURRENT)

1. WISH TO BE DEAD:

have you wished you were dead or wish you could go to sleep and not wake up? NO

if yes, describe:

2. NON-SPECIFIC ACTIVE SUICIDAL THOUGHTS:

have you had any thoughts of killing yourself? Yes.

if yes, describe:

3. ACTIVE SUICIDAL IDEATIONS WITH ANY METHODS (NOT PLAN) WITHOUT INTENT TO ACT

have you been thinking about how you might do this? No

if yes, describe:

4. ACTIVE SUICIDAL IDEATIONS WITH SOME INTENTS TO ACT, WITHOUT SPECIFIC PLAN

have you had these thoughts and had some intentions of acting on them? No

if yes, describe:

5.ACTIVE SUICIDAL IDEATIONS WITH SPECIFIC PLAN AND INTENT

have you start to work out or worked out the details of how to kill yourself? No

if yes, describe:

C-SSRS (LIFETIME)

1. WISH TO BE DEAD.

have you wished you were dead or wish you could go to sleep and not wake up? No

if yes, describe:  

2. NON-SPECIFIC ACTIVE SUICIDAL THOUGHTS: In the past, not now.

have you had any thoughts of killing yourself? YES

if yes, describe:

3. ACTIVE SUICIDAL IDEATIONS WITH ANY METHODS (NOT PLAN) WITHOUT INTENT TO ACT

have you been thinking about how you might do this? No

if yes, describe: Pills

4. ACTIVE SUICIDAL IDEATIONS WITH SOME INTENTS TO ACT, WITHOUT SPECIFIC PLAN.

have you had these thoughts and had some intentions of acting on them? YES

if yes, describe: Opened window and thought of jumping out of the window

5.ACTIVE SUICIDAL IDEATIONS WITH SPECIFIC PLAN AND INTENT: NO

have you start to work out or worked out the details of how to kill yourself? No

if yes, describe:

PROTECTIVE FACTORS: Family (Father and stepmother)

RISK ASSESSMENT: Low

SAFETY PLAN RECOMMENDATIONS: TO CALL 911 IF FEELING SUICIDAL

Psychosis: Y/N No

Diagnosis Formulation: Bipolar Disorder.

Score on Administered Screening Tool: PHQ score 10/27

Subjective

The patient is an 18-year-old male in for an initial psychiatric evaluation with consent. He is accompanied by his father and stepmother for the evaluation. Marc reports feeling good right now; he states, ” I was diagnosed with ADHD and Bipolar disorder, I am taking Seroquel 50mg and stopped taking Adderall 3 years ago”. They report wanting to with a new psychiatrist because the other did not have counseling services.

Assessment

The patient is in for an initial psychiatric evaluation; he reports a previous diagnosis of bipolar disorder and ADHD, and actively taking Seroquel 50mg at night. Patient reports feeling good and having no concerns but wanting continuation of care due to lack of available therapy at his previous provider.

Patient reports a troubled upbringing with divorced parents, expulsion from middle school, bullying, arguments with his mother, and occasional thoughts of suicide in the past.

He reports auditory hallucinations stating where he would see a window and think about jumping out of the window but did not act on the hallucination. A recommendation to increase his prescribed Seroquel to 75mg based on his reported auditory hallucinations and poor sleep was made to patient, however, he declined to increase the dosage stating he is okay. He is educated that if these auditory hallucinations persist and cause him to enact harm on himself or others, he should call 911.

Patient will continue Seroquel 50 mg nightly, and a referral for psychotherapy will be escalated. He is educated on medication compliance to improve his mood symptoms. He is educated on medication side effects and adverse effects. Education is provided on positive coping mechanisms to improve his mood.

A discussion was held with Marc’s father who is present during the interview. He expresses his wish to start patient back on his Adderall as he is about to enter college. The father is educated that Adderall will not be prescribed at this time because patient may be able to make behavioral adjustments through psychotherapy sessions and increased engagement in other activities. A reevaluation will be needed to diagnose patient with ADHD. Otherwise, his father is encouraged to continue actively supporting and maintaining open communication with patient.

Plan of Care:

Client will have decreased mood symptoms within 90 days

Client is referred for psychotherapy sessions weekly

Client will continue Seroquel 50mg at bedtime

Client is educated on medication side effects and adverse effects

Follow up in 2 weeks on 3/29/22

Call 911 for suicidal or homicidal ideations

Focused SOAP Note And Patient Case Presentation

 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. 

Focused SOAP Note and Patient Case Presentation

 Patient is an alert and oriented 33-year-old African American female seen via telehealth with consent with chief complaint of not feeling good about herself and feeling hopeless, helpless and worthless. She reports she is stressed because she has four children and no financial or emotional support from any of the four fathers. She reports a prior suicide attempt in 2012 via an overdose of muscle relaxants and oxycontin. At discharge from hospital, she was started on Wellbutrin and clonidine. She reports the Wellbutrin worked but the clonidine made her fuzzy. She has a history of asthma. She has NKDA. She has a history of asthma and uses and uses an Albuterol inhaler PRN. Hospitalized in 2012 for overdose and childbirth. She has four children ages 14, 11, 5 and 1. She reports there is no family history of mental illness. Mom was primary caregiver. Dad seldomly around and not really significant in her life. She is not married. She is using IUD for contraception. She has no outstanding legal issues. She graduated from high school. She is currently working at Amazon. She reports she is only sleeping 5 to 6 of sleep and her “appetite is terrible.” She smokes marijuana daily, smokes cigarettes, and consumes alcohol. She reports increased use of alcohol this week to manage her stress.

Diagnosis: MDD. PHQ-9 20/27.

Patient is an alert and oriented 33-year-old African American female with complaint of worthlessness, hopelessness, and helplessness who has a prior history of overdose suicide attempt with pills. She was treated with Wellbutrin and clonidine in the past. She had a good response to Wellbutrin. Clonidine left her fuzzy. I will restart Wellbutrin 150mg to address her depression and Vistaril 25 mg by mouth prn, every 8 hours for sleep and anxiety. I instructed her in the use of Wellbutrin, it will help her to decrease her tobacco intake. I instructed her that she cannot smoke marijuana or consume marijuana. It will affect absorption of the medications. Patient verbalized understanding. I instructed patient in sleep hygiene and to go to bed at a routine time and get up at same time. I discussed eating a healthy diet and exercise to promote an overall good healthy feeling and increase natural serotonin. Patient verbalized understanding. I instructed her to do something of interest, that brings her pleasure and to avoid eating after 7pm. Patient verbalized understanding. Patient will need psychotherapy to manage her stress and anxiety and provide instruction on coping skills.

Plan: In 90 days patient will have decreased symptoms of depression.

Patient will adhere to medication instructions of Wellbutrin 150mg and Vistaril 25 mg.

Instructed patient to call 911 for suicidal or homicidal thoughts. Patient verbalized understanding.

Patient referred to psychotherapy. Instructed patient to follow-up to ensure she is on schedule for psychotherapy.

Focused SOAP Note And Patient Case Presentation

Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. 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 4 weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient. 

 

Focused SOAP Note and Patient Case Presentation

Focused SOAP Note and Patient Case Presentation

Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. 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 4 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

· 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 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.

Focused SOAP Note and Patient Case Presentation

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

Focused SOAP Note and Patient Case Presentation

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 demonstrate you have indeed assessed for illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)

EXEMPLAR BEGINS HERE

Subjective:

CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:

N.M. is a 34-year-old Asian male presents for medication management follow up for anxiety. He was initiated sertraline last appt which he finds was effective for two weeks then symptoms began to return.

Or

P.H., a 16-year-old Hispanic female, presents for follow up to discuss previous psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications as we deferred until further testing and screening was conducted.

Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.

Paint a picture of what is wrong with the patient. First what is bringing the patient to your follow up evaluation? Document symptom onset, duration, frequency, severity, and impact. What has worsened or improved since last appointment? What stressors are they facing? Your description here will guide your differential diagnoses into your diagnostic impression. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns

ROS: Cover all body systems that may help you include or rule out a differential diagnosis. Please note: THIS IS DIFFERENT from a physical examination!

You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Objective:

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

Assessment:

Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.

He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking.   He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good. 


Diagnostic Impression: You must begin to narrow your differential diagnosis to your diagnostic impression. You must explain how and why (your rationale) you ruled out any of your differential diagnoses. You must explain how and why (your rationale) you concluded to your diagnostic impression. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection a discussion related to legal/ethical considerations (demonstrating 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.).



Case Formulation and Treatment Plan 

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions including psychotherapy and/or psychopharmacology, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. *See an example below. You will modify to your practice so there may be information excluded/included. If you are completing this for a practicum, what does your preceptor document?

Risks and benefits of medications are discussed including non- treatment. Potential side effects of medications discussed (be detailed in what side effects discussed). Informed client not to stop medication abruptly without discussing with providers. Instructed to call and report any adverse reactions. Discussed risk of medication with pregnancy/fetus, encouraged birth control, discussed if does become pregnant to inform provider as soon as possible. Discussed how some medications might decreased birth control pill, would need back up method (exclude for males).

Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. Discussed how drugs/alcohol affect mental health, physical health, sleep architecture.

Initiation of (list out any medication and why prescribed, any therapy services or referrals to specialist):

Client was encouraged to continue with case management and/or therapy services (if not provided by you)

Client has emergency numbers: Emergency Services 911, the Client’s Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)

Reviewed hospital records/therapist records for collaborative information; Reviewed PMP report (only if actually completed)

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (this relates to informed consent; you will need to assess their understanding and agreement)

Follow up with PCP as needed and/or for:

Labs ordered and/or reviewed (write out what diagnostic test ordered, rationale for ordering, and if discussed fasting/non fasting or other patient education)

Return to clinic:

Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care.



References (move to begin on next page)

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

© 2021 Walden University Page 1 of 3

Focused SOAP Note and Patient Case Presentation

Rubric Detail

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

Content

Name: PRAC_6665_Week7_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 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.

Feedback:

Points:

Points Range:
8 (8%) – 8 (8%)

The video accurately 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.

Feedback:

Points:

Points Range:
7 (7%) – 7 (7%)

The video 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, but is somewhat vague or contains minor inaccuracies.

Feedback:

Points:

Points Range:
0 (0%) – 6 (6%)

The video presents an incomplete, inaccurate, or unnecessarily detailed/verbose description of 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. Or subjective documentation is missing.

Feedback:

Discuss Objective data:

• 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

Points:

Points Range:
9 (9%) – 10 (10%)

The video accurately and concisely documents the patient’s physical exam for pertinent systems. Pertinent diagnostic tests and their results are documented, as applicable.

Feedback:

Points:

Points Range:
8 (8%) – 8 (8%)

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are documented, as applicable.

Feedback:

Points:

Points Range:
7 (7%) – 7 (7%)

Documentation of the patient’s physical exam is somewhat vague or contains minor inaccuracies. Diagnostic tests and their results are documented but contain inaccuracies.

Feedback:

Points:

Points Range:
0 (0%) – 6 (6%)

The response provides incomplete, inaccurate, or unnecessarily detailed/verbose documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or objective documentation is missing.

Feedback:

Discuss results of Assessment:

• Results of the mental status examination

• Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. 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.

Points:

Points Range:
18 (18%) – 20 (20%)

The video accurately documents the results of the mental status exam.

Video presents at least three differentials in order of priority for a differential diagnosis of the patient, and a rationale for their selection. Response justifies the primary diagnosis and how it aligns with DSM-5 criteria.

Feedback:

Points:

Points Range:
16 (16%) – 17 (17%)

The video adequately documents the results of the mental status exam.

Video presents three differentials for the patient and a rationale for their selection. Response adequately justifies the primary diagnosis and how it aligns with DSM-5 criteria.

Feedback:

Points:

Points Range:
14 (14%) – 15 (15%)

The video presents the results of the mental status exam, with some vagueness or inaccuracy.

Video presents three differentials for the patient and a rationale for their selection. Response somewhat vaguely justifies the primary diagnosis and how it aligns with DSM-5 criteria.

Feedback:

Points:

Points Range:
0 (0%) – 13 (13%)

The response provides an incomplete, inaccurate, or unnecessarily detailed/verbose description of the results of the mental status exam and explanation of the differential diagnoses. Or assessment documentation is missing.

Feedback:

Discuss treatment Plan:

• A treatment plan for the patient that addresses psychotherapy; one health promotion activity and one patient education strategy; plan for treatment and management, including alternative therapies; pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters; and a rationale for the approaches selected.

Points:

Points Range:
18 (18%) – 20 (20%)

The video clearly and concisely outlines an evidence-based treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear and concise rationale for the treatment approaches recommended is provided.

Feedback:

Points:

Points Range:
16 (16%) – 17 (17%)

The video clearly outlines an appropriate treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear rationale for the treatment approaches recommended is provided.

Feedback:

Points:

Points Range:
14 (14%) – 15 (15%)

The response somewhat vaguely or inaccurately outlines a treatment plan for the patient and provides a rationale for the treatment approaches recommended.

Feedback:

Points:

Points Range:
0 (0%) – 13 (13%)

The response does not address the diagnosis or is missing elements of the treatment plan.

Feedback:

Reflect on this case. Discuss what you learned and what you might do differently.

Points:

Points Range:
5 (5%) – 5 (5%)

Reflections are thorough, thoughtful, and demonstrate critical thinking.

Feedback:

Points:

Points Range:
4 (4%) – 4 (4%)

Reflections demonstrate critical thinking.

Feedback:

Points:

Points Range:
3.5 (3.5%) – 3.5 (3.5%)

Reflections are somewhat general or do not demonstrate critical thinking.

Feedback:

Points:

Points Range:
0 (0%) – 3 (3%)

Reflections are incomplete, inaccurate, or missing.

Feedback:

Focused SOAP Note documentation

Points:

Points Range:
18 (18%) – 20 (20%)

The response clearly, accurately, and thoroughly follows the Focused SOAP Note format to document the selected patient case.

Feedback:

Points:

Points Range:
16 (16%) – 17 (17%)

The response accurately follows the Focused SOAP Note format to document the selected patient case.

Feedback:

Points:

Points Range:
14 (14%) – 15 (15%)

The response follows the Focused SOAP Note format to document the selected patient case, with some vagueness and inaccuracy.

Feedback:

Points:

Points Range:
0 (0%) – 13 (13%)

The response incompletely and inaccurately follows the Focused SOAP Note format to document the selected patient case.

Feedback:

Presentation style

Points:

Points Range:
5 (5%) – 5 (5%)

Presentation style is exceptionally clear, professional, and focused.

Feedback:

Points:

Points Range:
4 (4%) – 4 (4%)

Presentation style is clear, professional, and focused.

Feedback:

Points:

Points Range:
3.5 (3.5%) – 3.5 (3.5%)

Presentation style is mostly clear, professional, and focused

Feedback:

Points:

Points Range:
0 (0%) – 3 (3%)

Presentation style is unclear, unprofessional, and/or unfocused.

Feedback:

Show Descriptions

Show Feedback

Photo ID display and professional attire–

Levels of Achievement:

Excellent
5 (5%) – 5 (5%)

Photo ID is displayed. The student is dressed professionally.

Good
0 (0%) – 0 (0%)

 

Fair
0 (0%) – 0 (0%)

 

Poor
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–

Levels of Achievement:

Excellent
5 (5%) – 5 (5%)

The video does not exceed the 8-minute time limit.

Good
0 (0%) – 0 (0%)

 

Fair
0 (0%) – 0 (0%)

 

Poor
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

Levels of Achievement:

Excellent
9 (9%) – 10 (10%)

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.

Good
8 (8%) – 8 (8%)

The video accurately 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.

Fair
7 (7%) – 7 (7%)

The video 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, but is somewhat vague or contains minor inaccuracies.

Poor
0 (0%) – 6 (6%)

The video presents an incomplete, inaccurate, or unnecessarily detailed/verbose description of 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. Or subjective documentation is missing.

Feedback:

Discuss Objective data:

• 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–

Levels of Achievement:

Excellent
9 (9%) – 10 (10%)

The video accurately and concisely documents the patient’s physical exam for pertinent systems. Pertinent diagnostic tests and their results are documented, as applicable.

Good
8 (8%) – 8 (8%)

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are documented, as applicable.

Fair
7 (7%) – 7 (7%)

Documentation of the patient’s physical exam is somewhat vague or contains minor inaccuracies. Diagnostic tests and their results are documented but contain inaccuracies.

Poor
0 (0%) – 6 (6%)

The response provides incomplete, inaccurate, or unnecessarily detailed/verbose documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or objective documentation is missing.

Feedback:

Discuss results of Assessment:

• Results of the mental status examination

• Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. 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.–

Levels of Achievement:

Excellent
18 (18%) – 20 (20%)

The video accurately documents the results of the mental status exam.

Video presents at least three differentials in order of priority for a differential diagnosis of the patient, and a rationale for their selection. Response justifies the primary diagnosis and how it aligns with DSM-5 criteria.

Good
16 (16%) – 17 (17%)

The video adequately documents the results of the mental status exam.

Video presents three differentials for the patient and a rationale for their selection. Response adequately justifies the primary diagnosis and how it aligns with DSM-5 criteria.

Fair
14 (14%) – 15 (15%)

The video presents the results of the mental status exam, with some vagueness or inaccuracy.

Video presents three differentials for the patient and a rationale for their selection. Response somewhat vaguely justifies the primary diagnosis and how it aligns with DSM-5 criteria.

Poor
0 (0%) – 13 (13%)

The response provides an incomplete, inaccurate, or unnecessarily detailed/verbose description of the results of the mental status exam and explanation of the differential diagnoses. Or assessment documentation is missing.

Feedback:

Discuss treatment Plan:

• A treatment plan for the patient that addresses psychotherapy; one health promotion activity and one patient education strategy; plan for treatment and management, including alternative therapies; pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters; and a rationale for the approaches selected.–

Levels of Achievement:

Excellent
18 (18%) – 20 (20%)

The video clearly and concisely outlines an evidence-based treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear and concise rationale for the treatment approaches recommended is provided.

Good
16 (16%) – 17 (17%)

The video clearly outlines an appropriate treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear rationale for the treatment approaches recommended is provided.

Fair
14 (14%) – 15 (15%)

The response somewhat vaguely or inaccurately outlines a treatment plan for the patient and provides a rationale for the treatment approaches recommended.

Poor
0 (0%) – 13 (13%)

The response does not address the diagnosis or is missing elements of the treatment plan.

Feedback:

Reflect on this case. Discuss what you learned and what you might do differently.–

Levels of Achievement:

Excellent
5 (5%) – 5 (5%)

Reflections are thorough, thoughtful, and demonstrate critical thinking.

Good
4 (4%) – 4 (4%)

Reflections demonstrate critical thinking.

Fair
3.5 (3.5%) – 3.5 (3.5%)

Reflections are somewhat general or do not demonstrate critical thinking.

Poor
0 (0%) – 3 (3%)

Reflections are incomplete, inaccurate, or missing.

Feedback:

Focused SOAP Note documentation–

Levels of Achievement:

Excellent
18 (18%) – 20 (20%)

The response clearly, accurately, and thoroughly follows the Focused SOAP Note format to document the selected patient case.

Good
16 (16%) – 17 (17%)

The response accurately follows the Focused SOAP Note format to document the selected patient case.

Fair
14 (14%) – 15 (15%)

The response follows the Focused SOAP Note format to document the selected patient case, with some vagueness and inaccuracy.

Poor
0 (0%) – 13 (13%)

The response incompletely and inaccurately follows the Focused SOAP Note format to document the selected patient case.

Feedback:

Presentation style–

Levels of Achievement:

Excellent
5 (5%) – 5 (5%)

Presentation style is exceptionally clear, professional, and focused.

Good
4 (4%) – 4 (4%)

Presentation style is clear, professional, and focused.

Fair
3.5 (3.5%) – 3.5 (3.5%)

Presentation style is mostly clear, professional, and focused

Poor
0 (0%) – 3 (3%)

Presentation style is unclear, unprofessional, and/or unfocused.

Feedback:

Total Points: 100

Name: PRAC_6665_Week7_Assignment2_Rubric

Focused SOAP Note and Patient Case Presentation

Subjective

The patient is a 24-year-old female who was seen today for initial evaluation via video session with her consent. She is diagnosed with adjustment disorder. The patient stated, “I really didn’t want therapy, it is my mom who wants us to see therapy together”. She stated that she does not have a relationship with her mother. She stated, “I agreed to see a therapist because that is the only way to communicate with my mom”. She said that her mother initiated for them to come to CLAY for therapy. She said that her mother has lots of issues, that she is overbearing. The patient said that her mother is very controlling and emotionally discharges when she tries talking to her. The patient agrees to do family therapy with her mother. The patient stated that she is not on any medication currently, but stated, “I smoke marijuana a lot regularly every day”. The patient stated that she tried to commit suicide at age 13 because she took a whole bottle of Adderall because her mother was pressing her to be taking it, but she went to school, and she told the teacher what she did and the teacher to her to the hospital. She said that she stayed in the psychiatric hospital for a week. The patient stated that there is a history of family mental illness in both the father and mother’s sides of the family. The patient stated that her parents divorced when she was 7 years old. She said that her father was very abusive. She said that she lived with her mother until she turned 20 years old and moved out of the house. She stated, “I’m currently living with my ex-boyfriend, and trying to find a place for myself”. She said she was bullied in middle school, but for high school, her mother was her bully. The patient said that she graduated high school and worked as a property manager.

Objective:

The patient is alert and oriented x 4, to person, place, time, and situation. She appeared very neat and clean. Her eye contact is very intense. She is cooperative, her mood is euphoric, her affect is labile, the thought process is intact, and goal directed. Fair insight and judgment, cognitively intact. The patient is not on any medication currently. She reports tried to commit suicide when she was 13 years old by taking a whole bottle of Adderall with intention of committing suicide but was taken to the hospital on time by her teacher after she her teacher and she was hospitalized for one week in the psychiatric hospital. The patient denies visual or auditory hallucination currently. She denies suicidal or homicidal ideation presently.

Assessment:

Diagnosis: Adjustment Disorder. The rating scale for PHQ-9 is 6/27 and she has little or no anxiety or depression. The patient is a 24-year-old African American female, alert, and oriented x 4, to person, place, time, and situation. She was seen today for initial evaluation via video conference with consent. She is seeking family therapy to facilitate a healthy adult relationship with her mother. The patient is not currently taking any medication. This Patient is referred to individual therapy along with family therapy with the mother to help facilitate building their relationship. The patient stated that she is already seeing a therapist and that she is willing to commit to this new therapy with her mother, and she will be seeing each on different days. The patient will be followed-up in 4 weeks. The patient stated that she does not exercise, her eating is not that great, and her appetite fluctuates. The patient is advised/encouraged to commit to exercise to increase her natural serotonin, increase her overall immunity and good health. Also, she is encouraged to focus on positive coping skills like exercise, taking a walk, finding an activity that she enjoys, and try to surround herself with positive people. She is encouraged to slow down on cannabis consumption. The patient agreed and verbalized understanding. The patient denied visual or auditory hallucination. She denied suicidal or homicidal ideation currently. She is instructed to call 911 immediately if she experiences suicidal or homicidal ideation, and she verbalized understanding.

Plan of care: The patient will have increased adjustment to her mother in 90 days. The patient has been referred to individual psychotherapy along with family therapy with her mother. The patient was instructed to exercise daily to increase her overall good health, immunity, and natural serotonin. She is encouraged to start cutting down on cannabis intake. She agreed and verbalized understanding. Follow-up in 4 weeks. Call 911 if experiencing suicidal or homicidal. The patient verbalized understanding.