Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning
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.
Subjective
The patient is a 24-year-old female who was seen today for initial evaluation via video session with her consent. She is diagnosed with adjustment disorder. The patient stated, “I really didn’t want therapy, it is my mom who wants us to see therapy together”. She stated that she does not have a relationship with her mother. She stated, “I agreed to see a therapist because that is the only way to communicate with my mom”. She said that her mother initiated for them to come to CLAY for therapy. She said that her mother has lots of issues, that she is overbearing. The patient said that her mother is very controlling and emotionally discharges when she tries talking to her. The patient agrees to do family therapy with her mother. The patient stated that she is not on any medication currently, but stated, “I smoke marijuana a lot regularly every day”. The patient stated that she tried to commit suicide at age 13 because she took a whole bottle of Adderall because her mother was pressing her to be taking it, but she went to school, and she told the teacher what she did and the teacher to her to the hospital. She said that she stayed in the psychiatric hospital for a week. The patient stated that there is a history of family mental illness in both the father and mother's sides of the family. The patient stated that her parents divorced when she was 7 years old. She said that her father was very abusive. She said that she lived with her mother until she turned 20 years old and moved out of the house. She stated, “I’m currently living with my ex-boyfriend, and trying to find a place for myself”. She said she was bullied in middle school, but for high school, her mother was her bully. The patient said that she graduated high school and worked as a property manager.
Objective:
The patient is alert and oriented x 4, to person, place, time, and situation. She appeared very neat and clean. Her eye contact is very intense. She is cooperative, her mood is euphoric, her affect is labile, the thought process is intact, and goal directed. Fair insight and judgment, cognitively intact. The patient is not on any medication currently. She reports tried to commit suicide when she was 13 years old by taking a whole bottle of Adderall with intention of committing suicide but was taken to the hospital on time by her teacher after she her teacher and she was hospitalized for one week in the psychiatric hospital. The patient denies visual or auditory hallucination currently. She denies suicidal or homicidal ideation presently.
Assessment:
Diagnosis: Adjustment Disorder. The rating scale for PHQ-9 is 6/27 and she has little or no anxiety or depression. The patient is a 24-year-old African American female, alert, and oriented x 4, to person, place, time, and situation. She was seen today for initial evaluation via video conference with consent. She is seeking family therapy to facilitate a healthy adult relationship with her mother. The patient is not currently taking any medication. This Patient is referred to individual therapy along with family therapy with the mother to help facilitate building their relationship. The patient stated that she is already seeing a therapist and that she is willing to commit to this new therapy with her mother, and she will be seeing each on different days. The patient will be followed-up in 4 weeks. The patient stated that she does not exercise, her eating is not that great, and her appetite fluctuates. The patient is advised/encouraged to commit to exercise to increase her natural serotonin, increase her overall immunity and good health. Also, she is encouraged to focus on positive coping skills like exercise, taking a walk, finding an activity that she enjoys, and try to surround herself with positive people. She is encouraged to slow down on cannabis consumption. The patient agreed and verbalized understanding. The patient denied visual or auditory hallucination. She denied suicidal or homicidal ideation currently. She is instructed to call 911 immediately if she experiences suicidal or homicidal ideation, and she verbalized understanding.
Plan of care: The patient will have increased adjustment to her mother in 90 days. The patient has been referred to individual psychotherapy along with family therapy with her mother. The patient was instructed to exercise daily to increase her overall good health, immunity, and natural serotonin. She is encouraged to start cutting down on cannabis intake. She agreed and verbalized understanding. Follow-up in 4 weeks. Call 911 if experiencing suicidal or homicidal. The patient verbalized understanding.
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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 diagnostic criteria for each differential diagnosis and explain what DSM-5 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 !), 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!), 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.
© 2021 Walden University Page 1 of 3
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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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Rubric Detail
Select Grid View or List View to change the rubric's layout.
Content
Name: PRAC_6665_Week7_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 fol
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