FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION
PART 1
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
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.
THE ASSIGNMENT
Record yourself presenting the complex case for your clinical patient.
Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video.
In your presentation:
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 FDA-approved 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 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. Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
PRAC 6665: PMHNP Care Across the Lifespan I
Faculty Name
Assignment Due Date
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
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:
© 2022 Walden University
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NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
PRECEPTOR VERFICIATION:
I confirm the patient used for this assignment is a patient that was seen and managed by the student at
their Meditrek approved clinical site during this quarter course of learning.
Preceptor signature: ________________________________________________________
Date: ________________________
References
© 2022 Walden University
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