Week 3: FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION, PART 2
Please use the “Focused SOAP Note Template” attached to complete the assignment. I have also attached information of patient to complete assignment on.
This assignment is a graduate level Masters in Nursing Psychiatric Nurse Practitioner program, and the work should be reflective of the highest standards of graduate work. Please read and and follow assignment instructions and rubic
Please use APA 7 format only. Please use APA 7 format only. Please use USA based peer-reviewed, evidence-based articles in the past 5 years for references. Also attach PDFs of references.
Per our NP program; All discussions and assignments require supportive evidence which must be based on scholarly sources only, NOT dictionaries, encyclopedias, newspapers, commercial journals or public websites which will not be accepted. Examples of sources that are not acceptable include Stat Pearls, Mayo Clinic, GoodTherapy, etc.
Generally, literature that is cited should not be older than five years unless it is considered a classical work
Assignment instruction. Please read and complete assignment according to instructions. Please write original work.
Assignment and instructions:
FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION, PART 2
Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. 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 three 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 this week’s Learning Resources and consider the insights they provide. Select a patient of any age (either a child or an adult) that you examined during the last 3 weeks.
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.
Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
THE ASSIGNMENT
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).
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.
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 supported by the patient’s symptoms.
Plan: Describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session?
In your written plan include all the above as well as include one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are 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? Demonstrate your critical thinking.
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.
LEARNING RESOURCES:
Required Readings:
• Carlat, D. J. (2024). The psychiatric interview (5th ed.). Wolters Kluwer.
o Section III. Interviewing for Diagnosis: The Psychiatric Review of Symptoms (Chapters 22–23)
o Chapter 20 “How to Memorize the DSM-5-TR Criteria”
o Chapter 35 “Writing Up the Results of the Interview”
o Appendix A pages 294–300
o Appendix B pages 301–316
• Lorberg, B., Davico, C., Martsenkovskyi, D., & Vitiello, B. (2019). Principles in using psychotropic medication in children and adolescents.Links to an external site. In J. M. Rey & A. Martin (Eds), IACAPAP e-textbook of child and adolescent mental health (2019 ed., pp. 1–25). International Association for Child and Adolescent Psychiatry and Allied Professions. https://iacapap.org/_Resources/Persistent/45bdffb25befc353c9f61988e82105029504ab85/A.7-Psychopharmacology-2019.1.pdf
• MeditrekLinks to an external site.
https://edu.meditrek.com/Default.html
Note: Use this link to log into Meditrek to report your clinical hours and patient encounters.
• Document: Focused SOAP Note Template Download Focused SOAP Note Template(Word document)
• Document: Focused SOAP Note Exemplar Download Focused SOAP Note Exemplar(Word document)
Recommended
• Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.
The Patient Information:
A.P. 16-year-old Female.
Chief Complaint:
“I need help with my mental health”
History of Present Illness:
A.P is a 16-year-old Asian
Medical done recently and labs was ordered
Reports that she feels stressed out with school and family. States that in terms of family parents have been strict on grades.
Mentioned that she strides for perfect academic (people expect her to be in a particular grade)
Started dropping in grade after the pandemic
Stresses that she would disappoint her parents of she does not do well in school
Younger brother 9 years old and older sister (has dealt with the same issues but does not say much to her parents about her plans)
It does not seem / occur to her that she has.
Mentioned that she is really close to her sister and would talk to her about problems
Believes the cultural (parents from Vietnam)
Sister is going to a really good university
9th grade (career programs) tech heavy and pressuring her to get into it.
Patient wants to go into Art (does not like the class)
Describes problems with sleep, panic attacks, excessive worrying, inattentiveness at school, high energy for no reason,
periods of euphoria, poor focus and concerns about eating)
Listening to music and draw for hours (all my worries and struggles have gone away)
Can make characters (goes on for hours)
Patient was administered the PHQ-9 depression assessment test. Patient scored between 15-19, indicating that a
Moderately Severe
Depression is present. Actual score is 18 . difficult for patient to do your work, take care of things at home, or get along
with other people.
The GAD-7 is a self-administered questionnaire and screen to detect and determine the severity of Generalized Anxiety
Disorder. Patient obtained a result between 15-21, suggesting a Severe Anxiety Disorder. Scores above 10 suggest the
need for further evaluation. Actual score is 15. difficult for patient to do your work, take care of things at home, or get
along with other people.
Mood disorder questionnaire
Mentioned that her grandfather passed away recently
Have had thoughts of hurting self (cut self for a couple weeks. Has the thought but it dissipates after a minute or so)
It happens often enough than she wants it to be and suppresses it
Denies abuse
Sleep score confirms patient is having issues with sleep 15
Recommendation is for patient to start medication.
Questioning her identity. Bi or Pan or Lesbian.
Parents are not aware of patient sexuality / identity.
Believes their reaction would be negative if they are to open up to them
Spoke to her cousins about it and her sister knows she is LGBTQ
Dad is more likely be completely against it compared to her mom
Talked at length that it would bother her (questioned her identity from 6th grade)
States that she is ok with them never finding out and wanting to keep it a secret till she has to leave the house
She can only talk to her cousins and one of best friend
Emotional/Behavioral:
Sleep/Appetite: sleeping problems; difficulty falling asleep; difficulty staying asleep; no binge eating; not purging; no restrictive diet; no enuresis; no encopresis;
Depression/Mania: depressed; no crying spells; no anhedonia; no recent weight loss; no recent weight gain; change in appetite; no insomnia; no hypersomnia; not feeling tired; no inattention for at least 6 months, inconsistent with developmental level; indecisiveness; feelings of worthlessness and guilt; no thoughts of suicide; no feelings ofgrandeur; no decreased need for sleep; speech not pressured; no racing thoughts; no impulsive behavior;
Anxiety: anxiety; with persistent worry; restlessness; not irritable; not tiring easily; no unreasonable fears with compelling desire to avoid (phobia); no persistent senseless or very distasteful thoughts; no flashbacks; avoidance of stimuli; hypervigilance; no obsessions; no compulsion;
Behavior Problems:
ADHD: no inattention for at least 6 months, inconsistent with developmental level; no; no; no; no difficulty with organizing tasks and activites; ADHD checklist normal; no; not easily distracted from extraneous stimuli; not forgetful in daily activites;
Hyperactivity-Impulsivity: no; no hyperactivity for at least 6 months, inconsistent with developmental level; no; no restlessness;
Oppositional Defiant: no tantrums; no; no; no; no; not touchy or easily annoyed; not angry/resentful; no; no oppositional behavior; no hostility toward authority figures; impulsive behavior not resulting in serious assault or property damage;
Conduct Disorder: does not bully/threaten/intimidate; no impulsive initiation of fights; no violent behavior with a weapon; no physical cruelty to people; no cruelty to animals; not stealing unneeded objects; has not forced someone into sexual activity; no vandalism; not setting fires; not broken into house or buildings; does not lie/con/manipulate; no forgery/shoplifting; does obey rules/curfew; no running away; no school absenteeism;
Prior Psychological Treatment
no psychological counseling; no psychiatric therapy; no previous hospitalizations; no psychotropic agents;
Social History
living situation; with parents; no caregiver; living arrangement unknown; no pets in household;
Behavioral History: not a current every day smoker; not a current some day smoker; not a former smoker;
Alcohol: not using alcohol;
Drug Use: no drug use;
Habits: not sedentary; exercising regularly; exercise duration is unknown; exercise frequency is unknown;
Religion/Culture/Race: religious status; cultural background; racial background unknown;
Sexual History: sexual history;
Family History
family history reviewed; father not deceased; mother not deceased; unspecified number of children; parents not divorced; no family history of early deaths; no drug use; not using alcohol; no family history of mental illness (not intellectual disabilities); no diagnosis of suicide attempt; no death in family; no serious illness in family;
Home Environment: composition of household; persons reside in household ; no parent/child estrangement; discipline problems; no family problems; parents not divorced; no problems with siblings; no problems with parent or guardian; no problems with support person; no multiple divorces or separations; no social services;
Pediatric History: not adopted; not firstborn; secondborn; not youngest in family; number of siblings;
Legal/Law Issues: no history of legal problems; no current legal problems; no violent event;
Past Medical History
Diagnoses: no diagnosis of heart disease; no diagnosis of transient ischemic attack; no diagnosis of diabetes mellitus;
no diagnosis of coronary artery disease; no diagnosis of migraine headache; no known allergy; no diagnosis of cancer;
no diagnosis of head injury; no diagnosis of systemic HTN; no diagnosis of cancer; no diagnosis of post-traumatic stress disorder; anxiety; no dissociative disorder; no diagnosis of disorders of consciousness; no diagnosis of depersonalization disorder; no diagnosis of impulse control disorder;
Recent Events: no self-inflicted injuries; no diagnosis of eating disorder; no diagnosis of substance abuse;
Reported Medical History: no prior surgery;
Reported Physical Trauma: no motor vehicle traffic accident;
Education History: education history; educational level; not coping effectively; no self-damaging behavior; no problems with one’s peer group;
Work History: work history unknown;
Financial Status: financial status unknown;
Functional Status: psychosocial support is sufficient;
Review of Systems
Psychological Symptoms: no interpersonal relationship problems; currently dating; social isolation; socially inappropriate behavior; not re-experiencing/re-inacting traumatic event; ability to express warmth and tenderness; no death of close friend;
Mental Status
General Appearance: general appearance normal; clothing unremarkable; grooming normal;
Alertness: alert; not drowsy; attitude not distractible; not dissociated; not stuporous;
Orientation: to time, place, and person; not disoriented;
Memory: no memory loss;
Intelligence: estimated intelligence normal;
Insight: no impaired insight;
Judgement: judgement not impaired;
Mood: mood dysthymic; mood not euphoric; affect sad; mood anxious; mood not fearful; mood not angry; does not
look angered;
Affect: affect; tearful;
Speech and Language: speech difficulty; speech rate rapid;
Thought Process: no thought content impairment;
Behavior: no tics; normal gait and stance; attitude not uncooperative; mood calm; compulsive behavior; not overly dramatic; attitude not hostile;
Risk Assessment: no diagnosis of suicide attempt; not entertaining thoughts of suicide; no homicide risk;
Abuse: not sexually abused; no physically abused; no violent traumatic event during childhood; no violent traumatic; no reporting of individual safety concerns; no interpersonal problems with a parent;
Developmental History: good prenatal care; mother did not smoke during pregnancy; mother did not use alcohol prepartum; mother did not use IV drug prepartum; mother did not use DES prepartum; mother did not use cocaine prepartum; not premature birth; full term pregnancy; no premature delivery; no delayed milestones; immunizations up to date;
Attachment: no failure to develop normal attachment behavior; ability to express anger; no difficulty relating with others; no suspiciousness and marked evasiveness; no paranoid ideations concerned with hidden motives of others; patient’s reaction to provider: no suspicion, distrust, or dislike; not disinhibited; no suicidal ideation; no illusions (altered perception of real events / objects); no delusions; no derealization; no emotional lability; no difficulty communicating;
Session Notes:
Comments:
Assessment and Plan
1. GAD (generalized anxiety disorder) F41.1 (300.02):
2. MDD (major depressive disorder), recurrent episode, severe F33.2 (296.33):
Wellbutrin SR 100 mg tablet, 12 hr sustained-release: 1 mg once a day for 30 days for depression and anxiety
3. Insomnia disorder G47.00 (780.52):
Plan
Next appointment set for in 2 weeks
START: Wellbutrin 100mg
Discussed the risk of mixing medication with OTC drugs, herbal, alcohol or other illegal drugs.
Discussed how drugs/ETOH affects mental health, physical health and sleep among others.
Medication management follow up visit – Patient to schedule
Patient is agreeable with this plan and agrees to follow treatment regimen as discussed.
Please see emergency numbers:
National client’s crisis line/suicide hotline number – available 24/7:1-800-273-8255.
Patient explained If symptoms worsen or have thoughts of harming yourself or others,
Call 911 or go to the nearest emergency room.
Safety plan Reviewed.
In case of mental health emergency, please contact a crisis response number as listed below or call 911 or go to your nearest emergency room.
Also contact National Suicide Prevention Lifeline is a national network of local crisis centers that provides free and confidential emotional support to people in suicidal crisis or emotional distress 24 hours a day, 7 days a week. Phone: 1-800-273-8255
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