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-TR diagnostic criteria for each differential diagnosis and explain what
DSM-5-TR 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
!), social determinates of health, 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 wi
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
PRAC 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:Â
PRECEPTOR VERFICIATION:
I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.
Preceptor signature: ________________________________________________________
Date: ________________________
References
© 2022 Walden University
Page 1 of 3
Pt Name: M.B
Age: 72 Years old F.
Diagnosis: Generalized Anxiety Disorder/ Insomnia/ Bipolar Disorder
Chief Complain: Unable to sleep Pt is a 72 year old female, who presented to the clinic with her stating that she do not sleep well at night, most times she will stay up for 24 hours or more though she tried to cover up with day time naps. She is having problem processing a protein milk intake and she eats twice daily without snacks because she and her daughter do not have enough to eat at home. She has lost some weight recently. Pt was educated to see her social worker as regards to help with meals. She rated her anxiety to be an 8/10 with 10 being the highest. She stated that staying home contributed much to her anxiety level. Pt endorses hallucination due to CBD gummies she takes for pain. She sees patterns on the carpet and wall. She is not willing to give it up since that is the only thing that helps with her pain. She was a drug addict in her 20’s and contacted Hepatitis B from dirty needles. She was sexually abused in her childhood days while in the foster home. She had several abortions and was blessed with one child whom she is living with today. Her list of medications include Aripiprazole (ARIPiprazole) 5 MG Oral Tablet Buspirone HCl (busPIRone HCl) 5 MG Oral Tablet Hydroxyzine HCl (hydrOXYzine HCl) 25 MG Oral Tablet Lamotrigine (lamoTRIgine) 25 MG Oral Tablet Mirtazapine 15 MG Oral Tablet. Her medication was called in and she is follow up in a months time.
RESOURCES
· Carlat, D. J. (2017).Â
The psychiatric interview (4th ed.). Wolters Kluwer.
· Section II. The Psychiatric History (Chapters 14–18)
· Section III. Interviewing for Diagnosis: The Psychiatric Review of Symptoms (Chapters 23–24)
· Lorberg, B., Davico, C., Martsenkovskyi, D., & Vitiello, B. (2019).Â
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:Â
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