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.
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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: In your video, describe your treatment plan using clinical practice guidelines
supported by evidence-based practice. Include a discussion on your chosen FDAapproved psychopharmacologic agents and include alternative treatments available and
supported by valid research. All treatment choices must have a discussion of your
rationale for the choice supported by valid research. What were your follow-up plan and
parameters? What referrals would you make or recommend as a result of this
treatment session?
In your written plan include all the above as well as include one social determinant
of health according to the HealthyPeople 2030 (you will need to research) as applied
to this case in the realm of psychiatry and mental health. As a future advanced
provider, what are one health promotion activity and one patient education
consideration for this patient for improving health disparities and inequities in the
realm of psychiatry and mental health? Demonstrate your critical thinking.
Reflection notes: What would you do differently with this patient if you could conduct
the session again? If you are able to follow up with your patient, explain whether these
interventions were successful and why or why not. If you were not able to conduct a
follow up, discuss what your next intervention would be.
CASE STUDY
F.K is a 21 y/o AA male who was transferred by CPD to the ER for psychiatric
evaluation due to commanding auditory hallucination and bizarre behavior. Patient
stated, “I here hear voices telling me to kill my momma.” Per mom, patient has been
acting bizarre at home, reported suicidal thoughts and threatened mom and others
with bodily harm. Patient noted to be labile, disorganized, manic, easily agitates and
also responding to internal stimuli. Patient has psychiatry history of bipolar
disorder. He takes Zyprexa 10 mg PO daily but has not been compliant with his
medication has reported by mom. He was just discharged from a different
psychiatric hospital with DX. of acute psychosis. Patient broke up with his girlfriend
about 1 month ago. His UDS is positive for Benzodiazepine and THC. Alcohol level
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