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
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.
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
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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.
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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.
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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”.
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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
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