Assignment 2: Focused SOAP Note and Patient Case Presentation
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Assignment 2: Focused SOAP Note and Patient Case Presentation
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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:
o All SOAP notes must be signed, and each page must be initialed by your Preceptor. Note: Electronic signatures are not accepted.
o 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.
o 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 with a lab coat 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:
o 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?
o Objective: What observations did you make during the psychiatric assessment?
o 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.
o 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.
o 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.
By Day 7 of Week 9
Submit your Video and Focused SOAP Note Assignment. You must submit two files for the note, including a Word document and scanned PDF/images of each page that is initialed and signed by your Preceptor.
Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:
• Please save your Assignment using the naming co
Rubrics
Rubric Detail
Select Grid View or List View to change the rubric’s layout.
Name: PRAC_6665_Week9_Assignment2_Rubric
• Grid View
• List View
Excellent Good Fair Poor
Photo ID display and professional attire 5 (5%) – 5 (5%)
Photo ID is displayed. The student is dressed professionally. 0 (0%) – 0 (0%) 0 (0%) – 0 (0%) 0 (0%) – 0 (0%)
Photo ID is not displayed. Student must remedy this before grade is posted. The student is not dressed professionally.
Time 5 (5%) – 5 (5%)
The video does not exceed the 8-minute time limit. 0 (0%) – 0 (0%) 0 (0%) – 0 (0%) 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.)
Discuss Subjective data:
• Chief complaint
• History of present illness (HPI)
• Medications
• Psychotherapy or previous
psychiatric diagnosis
• Pertinent histories and/or ROS 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. 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. 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. 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.
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 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. 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. 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. 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.
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. 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. 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. 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. 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.
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. 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. 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. 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. 0 (0%) – 13 (13%)
The response does not address the diagnosis or is missing elements of the treatment plan.
Reflect on this case. Discuss what you learned and what you might do differently. 5 (5%) – 5 (5%)
Reflections are thorough, thoughtful, and demonstrate critical thinking. 4 (4%) – 4 (4%)
Reflections demonstrate critical thinking. 3.5 (3.5%) – 3.5 (3.5%)
Reflections are somewhat general or do not demonstrate critical thinking. 0 (0%) – 3 (3%)
Reflections are incomplete, inaccurate, or missing.
Focused SOAP Note documentation 18 (18%) – 20 (20%)
The response clearly, accurately, and thoroughly follows the Focused SOAP Note format to document the selected patient case. 16 (16%) – 17 (17%)
The response accurately follows the Focused SOAP Note format to document the selected patient case. 14 (14%) – 15 (15%)
The response follows the Focused SOAP Note format to document the selected patient case, with some vagueness and inaccuracy. 0 (0%) – 13 (13%)
The response incompletely and inaccurately follows the Focused SOAP Note format to document the selected patient case.
Presentation style 5 (5%) – 5 (5%)
Presentation style is exceptionally clear, professional, and focused. 4 (4%) – 4 (4%)
Presentation style is clear, professional, and focused. 3.5 (3.5%) – 3.5 (3.5%)
Presentation style is mostly clear, professional, and focused 0 (0%) – 3 (3%)
Presentation style is unclear, unprofessional, and/or unfocused.
Total Points: 100
Focused note 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:
References
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