Focused SOAP Note and Patient Case Presentation
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, usingÂ the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.
Â· 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.Â PleaseÂ Â Note:
Â· Based on your SOAP note of this patient, develop a case study presentation.
Â· Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignmentÂ will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffingÂ consultation video.
In your presentation:
Â· 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.
Â· Report normal diagnostic results as the name of the test and â€œnormalâ€ (rather than specific value). Abnormal results should be reported as a specific value.
Â· Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide:
Â·Â Subjective:Â 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?
Â·Â Objective:Â What observations did you make during the psychiatric assessment?
Â·Â Assessment:Â 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 withÂ Â DSM-5Â diagnostic criteria and supported by the patientâ€™s symptoms.
Â·Â Plan:Â describeÂ your treatmentÂ plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatmentsÂ available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What wereÂ yourÂ follow-up plan and parameters? What referrals would you make or recommend as a result of this treatmentÂ session?
Â· In your written plan include all the above as well asÂ includeÂ one social determinant of health according to the HealthyPeople 2030 (you will need to research)Â as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are oneÂ 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.
Â·Â Reflection notes:Â What would you do differently with this patient if you could conduct the session again?Â 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.
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