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.
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
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
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 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
Rubric Detail
Select Grid View or List View to change the rubric’s layout.
Content
Name: PRAC_6665_Week3_Assignment2_Rubric
Grid View
List View
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:
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,
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