Nurs 687 L Mini SOAP note Psychiatric/Behavioral Encounter Note Week 2
Mini SOAP note Psychiatric/ Behavioral encounter Note Consult: In office (Outpatient new patient ) Patient initial: K 42 y/o Female White CC:” I have been feeling so low and hopeless lately” . “ I feel like a burden to my family and friends” F31.32 Bipolar disorder, current episode depressed, moderate. Additional medical Hx: Anxiety , Bipolar disorder Family history: DM Allergies: lamotrigine (From LAMICTAL) Suicidal: No Homicidal: No Medications: Sertraline (Zoloft) 50 mg PO Daily . Olanzapine (Zyprexa) 15 mg PO at Bedtime . Mirtazapine (Remeron) 15 mg PO at Bedtime Safety Plan : Ameliorate/Eliminate depression Ameliorate/ Eliminate anxiety Eliminate mood swings. Improve insomnia Educate patient on medication compliance and medication side effects. Follow up in two weeks. Submit 1 Mini-SOAP note on a patient that you saw in clinic this week. Submit as a Word Document. See example template below for required format. Review the rubric for more information on how your assignment will be graded. Demographic Data • Patient initial (one initial only), age, and gender must be Health Insurance Portability and Accountability (HIPPA) compliant. Subjective • • • • • • • • Chief Complaint (CC) History of Present Illness (HPI) (symptoms) in paragraph format Past Medical History (PMH): Current problem-focused and document pertinent information only. Current Medications: Medication Allergies: Social History: For current problem-focused and document only pertinent information only. Family History: For current problem-focused and document only pertinent information only. Review of Systems (ROS) as appropriate: Objective • • • • Vital signs Mental Status Exam Physical findings listed by body systems, not paragraph form. Patient Health Questionnaires, Screenings, and the results (PHQ-9, GAD 7, suicidal) Assessment (Diagnosis/ICD10 Code) • • Include all diagnoses that apply to this visit. Include one differential diagnosis. Plan • • • • • Dx Plan (lab, x-ray) Tx Plan: (meds) Pt. Education, including specific medication teaching points. Safety Plan Referral/Follow-up *Based on population focus, some additional details may be required by faculty Top of Form Rubric Mini SOAP Note Mini SOAP Note Criteria Ratings This criterion is linked to a Learning OutcomeSubjective 15 to >12.0 pts Accomplished SOAP format is well organized, with C/C, History of present Illness, past medical history, Medications, Allergies, Social Hx, family history, and other pertinent past and current diagnostic details. SOAP Note is complete, concise, and relevant with no extraneous data 12 to >10.0 pts Satisfactory SOAP format is well organized, with C/C, History of present Illness, past medical history, Medications, Allergies, Social Hx, Family history, and other pertinent past and current diagnostic details. Some extraneous data is present, with one minor data point missing. 10 to >5.0 pts Needs Improvement SOAP format analysis is not well organized or presented in a varied format. Required data is missing. Too much extraneous data is present, or 2-3 data points are missing 5 to >0 pts Unsatisfacto Symptom an inadequate a organized. O or other data into the subj data. Critica missing This criterion is linked to a Learning OutcomeObjective 15 to >12.0 pts Accomplished The Mental Status Exam is complete, concise, wellorganized, and wellwritten. Includes pertinent psychiatric information. Organized by MSE list format. No extraneous information is included. 12 to >10.0 pts Satisfactory The Mental Status Exam is partially incomplete, organized, and satisfactorily written. Includes pertinent psychiatric information with additional extraneous details included. Somewhat organized in MSE list format. 10 to >5.0 pts Needs Improvement The Mental Status Exam is incomplete and loosely organized, with improvements required. Therefore, relevant psychiatric information is omitted. 5 to >0 pts Unsatisfactory Mental Status E absent, disorga presentation, a no specific form grossly omits r pertinent psych information. Mini SOAP Note Criteria Ratings This criterion is linked to a Learning OutcomeAssessment 15 to >12.0 pts Accomplished Diagnosis and Differential Dx are correct with DSM-5 code(s) and supported by subjective and objective data. Includes: 1 working Dx and 1 Differential Dx. 12 to >10.0 pts Satisfactory Diagnosis and Differential Dx are correct with DSM5 code(s) and supported mainly by subjective and objective data. One pertinent differential diagnosis is not listed according to subjective and objective data. However, the working diagnosis is correct. 10 to >5.0 pts Needs Improvement Diagnosis and Differential Dx are correct with DSM-5 code(s) and supported mainly by subjective and objective data. Missing pertinent differential diagnoses based on subjective and objective data presented. Or differential diagnoses are adequate with an incorrect working diagnosis. 5 to >0 pts Unsatisfact All diagnose (working an differential diagnoses) a incorrect or based on the subjective a objective da presented This criterion is linked to a Learning OutcomePlan 15 to >12.0 pts Accomplished The plan is well-organized, complete, evidence-based, and patient-centric. It comprehensively addresses the diagnosis and is individualized to the specific patient. *Plan requirements: prescribed medications, if any; explanation of off-label medication use, if prescribed; risks and benefits of medicines identified; therapy recommendations; patient education; referral/follow-up; and health maintenance. Total Points: 60 12 to >10.0 pts Satisfactory The plan is organized, complete, evidencebased, and patientcentric. It comprehensively addresses the diagnosis and is individualized to the specific patient. The plan is missing one of the required items. 10 to >5.0 pts Needs Improvement The plan is less organized and is not based on evidence. Fails to address each diagnosis sufficiently or is not individualized or patient-centric The plan is missing two or more of the required items. 5 to >0 Unsatis The pla disorgan absent, missing required PreviousNext
Collepals.com Plagiarism Free Papers
Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.
Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS
Why Hire Collepals.com writers to do your paper?
Quality- We are experienced and have access to ample research materials.
We write plagiarism Free Content
Confidential- We never share or sell your personal information to third parties.
Support-Chat with us today! We are always waiting to answer all your questions.
