Step 2: Each student will create a focused SOAP note PowerPoint presentation. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive psychiatric SOAP note is to be written using the attached template below.
S = Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS) O = Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam, (Focused), and Mental Status Exam A = Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes P = Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up
Other: Incorporate current clinical guidelines NIH Clinical Guidelines (Links to an external site.)or APA Clinical Guidelines (Links to an external site.), research articles, and the role of the PMHNP in your presentation.
- Psychiatric Assessment of Infants and Toddlers (Links to an external site.)
- Psychiatric Assessment of Children and Adolescents (Links to an external site.)
Reminder: It is important that you complete this assessment using your critical thinking skills. You are expected to synthesis your clinical assessment, formulate a psychiatric diagnosis, and develop a treatment plan independently. It is not acceptable to document “my preceptor made this diagnosis.” An example of the appropriate descriptors of the clinical evaluation is listed below. It is not acceptable to document “within normal limits.” MENTAL STATUS EXAM GUIDE
Previous Mental Health Treatments (e g: psychopharmacology, inpatient stabilization, Occupational
Therapy, Vocational Therapy, Marriage/Family Therapy, Group Therapy, Detox, ECT &/or social
What is the initial impression of the admitting examiner found in the initial evaluation, triage, or social
Compare your impression of the patient’s status now to the initial impression:
BRIEF MENTAL STATUS EXAM
Instructions; Most information can be obtained during an interaction with the patient without asking
specific questions. The information must be described to support your conclusion.
Appearance (e.g. grooming, manner of dress, level of hygiene, facial expression, remarkable
features, height, weight, nutritional status, presence of piercings, tattoos, scars, the relationship
between appearance and age, etc.):
Attitude toward examiner (INCLUDED IN BEHAVIOR) – Does the patient have good eye contact?
Are they cooperative, friendly, attentive, interested, frank, seductive, defensive, playful, apathetic,
evasive, guarded, etc.:
Speech characteristic –
What are the qualities of the patient’s speech include tone, inflection, volume, pronunciation
(clear or slurred; mumbling; defects, lisp, stuttering), speed:
What is the quantity of the patient’s speech? Does the patient verbalizes freely, provide
monosyllabic answers, have pressured speech, and/or are they hyperverbal:
Psychomotor activity (INCLUDED IN BEHAVIOR)
Is the patient experiencing hypoactive psychomotor activity that can include generalized
slowing down of body movements, aimless, purposeless activity, etc.? Write your description
Is the patient experiencing hyperactive psychomotor activity that can include restlessness,
agitation, combativeness, wringing of hands, pacing, etc.? Write your description and
conclusion: Submission Instructions: The presentation is original work and logically organized, formatted, and cited in the current APA style, including citation of references. The presentation should consist of 10-15 slides and less than 7 minutes in length (excluding the introduction and reference page). Incorporate a minimum of four current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work. Journal articles and books should be referenced according to APA style, 7th Edition (the library has a copy of the APA Manual).
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