In Weeks 4, 7, and 9 of the course, you will participate in clinical discussions called grand rounds. In one of these three weeks, you will be a presenter as wel
PLEASE FOLLOW INSTRUCTION BELOW, ZERO PLAGIARISM, FIVE REFERENCES NOT MORE THAN FIVE YEARS, SEE RUBRIC/TEMPLATE AND CASE STUDY ATTACHED, PLEASE FOLLOW THE 7TH APA WRITING STYLE/FORMAT
In Weeks 4, 7, and 9 of the course, you will participate in clinical discussions called grand rounds. In one of these three weeks, you will be a presenter as well as help facilitate the online discussion; in the others you will be an active discussion participant. When it is your week to present, you will create a Focused SOAP note and a short didactic (teaching) video presenting a real (but de-identified) complex patient case from your practicum experience.
You should have received an assignment from your Instructor letting you know which week of the course you are assigned to present.
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
PRAC 6675: PMHNP Care Across the Lifespan II
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
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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-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR 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 !), social determinates of health, 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 of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.
HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:
N.M. is a 34-year-old Asian male presents for medication management follow up for anxiety. He was initiated sertraline last appt which he finds was effective for two weeks then symptoms began to return.
Or
P.H., a 16-year-old Hispanic female, presents for follow up to discuss previous psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications as we deferred until further testing and screening was conducted.
Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.
Paint a picture of what is wrong with the patient. First what is bringing the patient to your follow up evaluation? Document symptom onset, duration, frequency, severity, and impact. What has worsened or improved since last appointment? What stressors are they facing? Your description here will guide your differential diagnoses into your diagnostic impression. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.
Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.
Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.
Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns
ROS: Cover all body systems that may help you include or rule out a differential diagnosis. Please note: THIS IS DIFFERENT from a physical examination!
You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
Objective:
Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
Assessment:
Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.
He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.
Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?
Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), social determinates of health, 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.).
Case Formulation and Treatment Plan
Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions including psychotherapy and/or psychopharmacology, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. *See an example below. You will modify to your practice so there may be information excluded/included. If you are completing this for a practicum, what does your preceptor document?
Risks and benefits of medications are discussed including non- treatment. Potential side effects of medications discussed (be detailed in what side effects discussed). Informed client not to stop medication abruptly without discussing with providers. Instructed to call and report any adverse reactions. Discussed risk of medication with pregnancy/fetus, encouraged birth control, discussed if does become pregnant to inform provider as soon as possible. Discussed how some medications might decreased birth control pill, would need back up method (exclude for males).
Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. Discussed how drugs/alcohol affect mental health, physical health, sleep architecture.
Initiation of (list out any medication and why prescribed, any therapy services or referrals to specialist):
Client was encouraged to continue with case management and/or therapy services (if not provided by you)
Client has emergency numbers: Emergency Services 911, the Client's Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)
Reviewed hospital records/therapist records for collaborative information; Reviewed PMP report (only if actually completed)
Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (this relates to informed consent; you will need to assess their understanding and agreement)
Follow up with PCP as needed and/or for:
Labs ordered and/or reviewed (write out what diagnostic test ordered, rationale for ordering, and if discussed fasting/non fasting or other patient education)
Return to clinic:
Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care.
References (move to begin on next page)
You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
© 2022 Walden University Page 1 of 3
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Grand Rounds Discussion: Complex Case Study Presentation
In Weeks 4, 7, and 9 of the courses, you will participate in clinical discussions called grand rounds. In one of these three weeks, you will be a presenter as well as help facilitate the online discussion; in the others you will be an active discussion participant. When it is your week to present, you will create a Focused SOAP note and a short didactic (teaching) video presenting a real (but de-identified) complex patient case from your practicum experience.
You should have received an assignment from your instructor letting you know which week of the course you are assigned to present.
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 child/adolescent or adult patient from your clinical experience that presents with a significant concern. Create a focused SOAP note for this patient using the template in the Resources. All SOAP notes must be signed, and each page must be initialed by your Preceptor. When you submit your SOAP note, you should include the complete 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. Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.
· Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice what you will say beforehand, and ensure that you have the appropriate lighting and equipment to record the presentation.
· Your presentation should include objectives for your audience, at least 3 possible discussion questions/prompts for your classmates to respond to, and at least 5 scholarly resources to support your diagnostic reasoning and treatment plan.
Video assignment for this week’s presenters:
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).
· State 3–4 objectives for the presentation that are targeted, clear, use appropriate verbs from Bloom’s taxonomy, and address what the audience will know or be able to do after viewing.
· 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.
· Pose three questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.
· 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 is 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 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.
A note on grading:
· Presenters: Review the Grand Rounds Presenter Rubric to ensure you meet the scoring criteria.
· Participants: Review the Grand Rounds Participant Rubric to ensure you meet the scoring criteria.
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My Patient Case Study:
Patient is a 44-year-old African American male seen today for an initial evaluation and treatment with consent obtained. Patent stated, " I am struggling. I try to make things happen and stay on track. I am having hard time communicating with my family and my children, I feel paranoid and separated from everything. I know that this is not me, I need help to handle stress". Patient reported that he was discharge from psychiatrist hospital six-month ago. And since then, he has not seen any provider. Patient reports feelings of irritability, anger, paranoia, and inability to handle pressure. Patient currently lives alone and rents a room in a house, has a small group friend. Patient is on disability, and is distanced from his children and extended family. Patient further stated both the mother and father side have some mental illness. He hopes to regain motivation, attentiveness, and confidence so he can develop a better relationship with his family. Patient is currently on Wellbutrin 150mg by mouth daily for depression which was prescribed by his PCP. Patient reported no changes his depressive mood despite the fact he has been on this medication for six months or more. Provider increased the Wellbutrin to 300mg by mouth daily and Hydroxyzine 25mg by mouth every 8hrs as needed for Anxiety. Patient was educated to take Wellbutrin 300mg daily in the morning to help decrease his depression and increase his overall drive to accomplish his goals of confidence, motivation, and attentiveness. Patient denies suicidal or homicidal ideation. Patient was educated to monitor side/adverse effect and drug interaction of the medication which he some verbalized understanding. Patient will be referred for psychotherapy sessions for education on anger and stress management. Patient is educated on positive coping mechanisms to improve his mood. Patient verbalizes understanding.
PHQ Score is 15/27
Vital Sign Temp-98.6, Res-20, Pulse-76, B/P-138/82, Weight-188lbs
Patient will continue Wellbutrin 300mg daily to decrease depressive mood and Hydroxyzine 25m as needed for Anxiety.
Patient will be educated on medication side effects and adverse effects
Patient to follow up with psychotherapy
Patient will be educated on positive coping mechanisms to improve mood
Follow up in 2 weeks
Call 911 if experiencing suicidal or homicidal ideations.
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Rubric Detail
Select Grid View or List View to change the rubric's layout.
Content
Name: PRAC_6675_Week4_Discussion_Presenter_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 with a lab coat. 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 with a lab coat. 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 the 8 minutes will not be evaluated for grade inclusion.) Feedback: |
| Objectives for the Presentation | Points: Points Range: 5 (5%) – 5 (5%) 3–4 objectives provided and written in terms of what the audience will know or be able to do after viewing. Appropriate Bloom's verbs are used. Objectives are targeted and clear. Feedback: | Points: Points Range: 4 (4%) – 4 (4%) 3–4 objectives provided and written in terms of what the audience will know or be able to do after viewing. Appropriate Bloom's verbs are used. Feedback: | Points: Points Range: 3.5 (3.5%) – 3.5 (3.5%) At least 3 objectives provided and written in terms of what the audience will know or be able to do after viewing, but are somewhat vague or unclear. Appropriate Bloom's verbs may be missing. Feedback: | Points: Points Range: 0 (0%) – 3 (3%) Fewer than 3 objectives provided. Objectives for the presentation are vague, unclear, or missing. 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: 5 (5%) – 5 (5%) The video is a Kaltura video and 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: 4 (4%) – 4 (4%) The video is not a Kaltura video but easily opened and 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: 3.5 (3.5%) – 3.5 (3.5%) The video is not a Kaltura video and did not open without needing to reach the student. The 2nd attempt 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%) – 3 (3%) There is no video submission or 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 3 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: |
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