Focused SOAP Note and Patient Case Presentation

Assignment 2: Focused SOAP Note and Patient Case Presentation

 

Photo Credit: Pexels

Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. 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 4 weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient. 

To Prepare

Review the Kaltura Media Uploader resource for help creating your self-recorded Kaltura video

• Select an adult patient that you examined during the last 4 weeks who presented with a disorder other than the disorder present in your Week 3 Case Presentation.

• 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.

 

 

 

 

PRAC_6665_Week7_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 chosen FDA-approved psychopharmacologic agents and includes alternative treatments available and supported by valid research. The treatment plan includes rationales, a plan for follow-up parameters, and referrals. The discussion includes one social determinant of health according to the HealthyPeople 2030, 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., 18 (18%) – 20 (20%)The video clearly and concisely outlines an evidence-based treatment plan for the patient that addresses FDA-approved psychopharmacologic agents and includes alternative treatments and rationale supported by valid research.

 

Discussion includes a clear and concise follow-up plan and parameters.

 

The discussion includes a clear and concise referral plan.

 

The paper discussion contains all 3 elements from the assignment directions including a discussion demonstrating critical thinking of the case related to the HealthyPeople 2030 social health determinates. Clearly and concisely relates discussion to the psychiatric and mental health field., 16 (16%) – 17 (17%)The video clearly outlines an appropriate treatment plan without evidence-based discussion for the patient that addresses FDA-approved psychopharmacologic agents and includes alternative treatments and rationale supported by vague or questionable research.

 

Discussion includes a clear follow-up plan and parameters.

 

The discussion includes a clear referral plan.

 

The paper discussion contains 2 of the elements from the assignment directions with one being a basic discussion of the case related to the HealthyPeople 2030 social health determinates. Clearly relates discussion to the psychiatric and mental health field., 14 (14%) – 15 (15%)The response somewhat vaguely or inaccurately outlines a treatment plan for the patient that addresses psychopharmacologic agents without discussion of FDA approval and includes vague or inaccurate alternative treatments with little rationale discussed.

 

The discussion is somewhat vague or inaccurate regarding the follow-up plan and parameters.

 

The discussion is somewhat vague or inaccurate regarding a referral plan.

 

The paper discussion contains 1 of the required elements from the assignment directions which is the HealthyPeople 2030 social health determinates.

 

Somewhat vaguely or inaccurately relates discussion to the psychiatric and mental health field., 0 (0%) – 13 (13%)The response does not address the treatment plan or the treatment plan is not appropriate for the assessment and the diagnosis. There is no mention of FDA approval for treatment choices or no research supported discussion. Alternative treatment discussion is missing.

 

Rationales for treatments are missing.

 

There is no discussion for follow-up and parameters.

 

There is no discussion of a referral plan.

 

The paper discussion is missing discussion relating to the psychiatric and mental health field or relates discussion to another specialty realm including medical co-morbidity illnesses.

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.

 

 

Case presentation

Chief Complaint 

Monthly visit

 

patient for monthly mental health and medication evaluation.

History of Present Illness 

 

 

 

39yo male with PMH schizophrenia, substance abuse, R sciatica. Review of records show most recent BH presentation was an admission in June 2022; he also presented to the ED in Mar 2022 for BH concerns. Medical presentations include May 2022 ED visit for myalgia and vomiting. Mar 2022 ED visit for mask pain [R x-ray negative, c-spine x-ray negative]; Jan 2021 ED visit for testicular pain [u/s showed small L varicocele; chlamydia/gonorrhea negative]. Reported he hoped he could see PT/OT for back pain.

Problem List/Past Medical History 

 

History of Left varicocele

 

Sciatica

 

Suicide risk

 

Tobacco user

 

 

 

Home 

ALPRAZolam 0.5 mg oral tablet, 1mg= 2 tab, PO, 2x/day

Latuda, 40 mg= 1 tab, PO, Daily with dinner

 

hydrOXYzine, 50 mg= 1 tab, PO, 3x/day

 

celecoxib 200 mg oral capsule, 200 mg= 1 cap, PO, Daily

 

chlorpromazine 50 mg oral tablet, 50 mg= 1 tab, PO, 3x/day

 

gabapentin 300 mg oral capsule, 600 mg= 2 cap, PO, 3x/day

acetaminophen, 1000 mg= 2 tab, PO, q6h, PRN

 

 

nicotine 14 mg/24 hr transdermal film, extended release, 1 patch, Transdermal, Daily

 

Allergies 

 

No Known Allergies

 

Social History 

 

Smoking Status 

Current everyday smoker

 

 

Employment/School

 

 

Status: Employed. Work/School description: Pt works doing electrical engineering.

 

 

Exercise

 

 

Home/Environment

 

 

Comment(s): Pt is from Illinois. He got off the bus in DC on his way to Florida and has been here for three years. Living situation: Home/Independent.

 

 

Tobacco/Nicotine

 

 

Use: Current. Type: Cigarettes.

 

Family History 

Grandfather-Paternal:  MI – Myocardial infarction 

 

has previously denied fm hx of CVA, HTN, DM

 

Immunizations 

has previously denied receiving COVID vaccines

 

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