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

 

 

TO PREPARE

• Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
• 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.
  Please Note:
  • All SOAP notes must be signed, by your Preceptor. Note: Electronic signatures are not accepted.
  • When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of the completed assignment signed by your Preceptor.
  • You must submit your SOAP note using Turnitin. Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.
• Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record.
• Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
• Ensure that you have the appropriate lighting and equipment to record the presentation.

 

 

** I started the assignment and am sharing it below 

 

Subjective:

CC “ My anxiety is bad. I have sweaty palms.”

HPI: PG is a 29-year-old white male who presented to the office for a psychotropic medication session and evaluation due to increased anxiety, irritability, and a severe lack of motivation. He has a history of poor sleep, irritability, depression, and multiple substance relapses. The patient presented to the office because his anxiety was getting out of hand. He describes his concern as so bad that it makes him nauseous, and he has sweaty palms. The patient has a history of alcohol and cocaine abuse. He has been to Detox many times but still struggles with sobriety. He has previously missed a couple of appointments and blames it on his alcohol dependence. 

Substance Current Use: The patient has a long history of substance use; he started abusing alcohol when he was 14. He is also dependent on cocaine and marijuana. He also smokes a pack of cigarettes daily. 

Medical History:

 

The patient denies any medical issues. 

 

• Current Medications: 

Acamprosate, propranolol, sertraline, naltrexone,mirtazapine, Bupropion

• Allergies: 

No known allergies

• Reproductive Hx: 

The patient is not married and does not have any children.

ROS: 

• GENERAL: No weight loss, fever, weakness, poor appetite, and increased fatigue
• HEENT: Eyes: No visual loss, dry eyes, no double vision, or pain. Ears, Nose, Throat: No hearing loss, runny nose/ congestion, or sore throat. 
• SKIN:    No rash or dryness, no dryness.
• CARDIOVASCULAR: No chest pain or discomfort, no palpitation, no edema 
• RESPIRATORY: No shortness of breath, coughing, no sputum. 
• GASTROINTESTINAL: poor appetite, no diarrhea, no abdominal pain. 
• GENITOURINARY: No burning sensation or hesitancy, no incontinence
• NEUROLOGICAL: No syncope, dizziness, headaches, no numbness.
• MUSCULOSKELETAL: No stiffness, no muscle pain, no joint pain. 
• HEMATOLOGIC: No bruising/ bleeding, no anemia.
• LYMPHATICS: No enlarged nodes, no history of splenectomy
• ENDOCRINOLOGIC: No cold or heat intolerance, excessive thirst, or excessive urination.

Objective:

Vital signs: T 98.1. HR 70, RR 20, BP 132/72, Weight 172.  Height 69 inches, 

Diagnostic results:  No diagnostic results were ordered. 

Assessment:

Mental Status Examination: 

The patient is 29 years old white male, a young-appearing adult of average height and builds, dressed appropriately for the weather in clean clothing. The patient is alert and oriented, with good eye contact. Facial expression is flexible. The demeanor is socially appropriate. No akathisia, tremors or abnormal involuntary movement was noted during the interview. He speaks English of speed, amplitude, and quantity, generally WNL. Thought associations are more coherent. No imminent SI or HI  intention was expressed during the interview. No paranoia, delusions, hallucinations, illusions, or ideas of reference are apparent.  He does not seem to be responding to internal stimuli. The mood is euthymic. Affect is congruent with mood. The patient generally is oriented to person, place, and time. He has good insight with intact recent and remote memory. 

 

 

** KINDLY START FROM HERE 

Diagnostic Impression:

 

Reflections:

Case Formulation and Treatment Plan:

 

 

 

* The patient’s DX are major depressive disorder, Generalized anxiety, alcohol use, and opioid abuse disorder,

 

 

The following is the THE FOCUSSED SOAP NOTE EXAMPLER

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

 

 

NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation
Exemplar
© 2022 Walden University Page 3 of 6
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

 

 

NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation
Exemplar
© 2022 Walden University Page 4 of 6
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.
Diagnostic Impression: You must begin to narrow your differential diagnosis to your
diagnostic impression. You must explain how and why (your rationale) you ruled out
any of your differential diagnoses. You must explain how and why (your rationale) you
concluded to your diagnostic impression. You will use supporting evidence from the

 

 

NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation
Exemplar
© 2022 Walden University Page 5 of 6
literature to support your rationale. Include pertinent positives and pertinent negatives
for the specific patient case.
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!), 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.).
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)

 

 

NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation
Exemplar
© 2022 Walden University Page 6 of 6
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

 

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