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. Get custom essay samples and course-specific study resources via course hero homework for you service – Include pertinent positives and pertinent negatives for the specific patient case.
• Read rating descriptions to see the grading standards!
Reflect on this case. Get custom essay samples and course-specific study resources via course hero homework for you service – Include : Ace my homework – Write my paper – Online assignment help tutors – 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 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. Get custom essay samples and course-specific study resources via course hero homework for you service – Include the daily amount of use and last known use. Get custom essay samples and course-specific study resources via course hero homework for you service – Include type of use such as inhales, snorts, IV, etc. Get custom essay samples and course-specific study resources via course hero homework for you service – Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.
Current Medications: Get custom essay samples and course-specific study resources via course hero homework for you service – Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.
Allergies: Get custom essay samples and course-specific study resources via course hero homework for you service – 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. I need help writing my essay – research paper 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: Get custom essay samples and course-specific study resources via course hero homework for you service – 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 literature to support your rationale. Get custom essay samples and course-specific study resources via course hero homework for you service – 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
Get custom essay samples and course-specific study resources via course hero homework for you service – Include s 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. Ace my homework – Write my paper – Online assignment help tutors – Discussed risk of medication with pregnancy/fetus, encouraged birth control, discussed if does become pregnant to inform provider as soon as possible. Ace my homework – Write my paper – Online assignment help tutors – Discussed how some medications might decreased birth control pill, would need back up method (exclude for males).
Ace my homework – Write my paper – Online assignment help tutors – Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. Ace my homework – Write my paper – Online assignment help tutors – 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 Ace homework tutors – APA 7th edition formatting.
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan II
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
To Prepare
• Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing anxiety, obsessive compulsive, and trauma-related disorders.
• Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
• Review the video, Case Study: Dev Cordoba. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
• Consider what history would be necessary to collect from this patient.
• Consider what interview questions you would need to ask this patient.
The Assignment
Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:
• 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: Ace my homework – Write my paper – Online assignment help tutors – Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TRcriteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Get custom essay samples and course-specific study resources via course hero homework for you service – Include pertinent positives and pertinent negatives for the specific patient case.
• Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Get custom essay samples and course-specific study resources via course hero homework for you service – Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.
• Reflection notes: What would you do differently with this patient if you could conduct the session again? Ace my homework – Write my paper – Online assignment help tutors – Discuss what your next intervention would be if you could follow up with this patient. 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.).
• Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).
Learning Resources
Required Readings (click to expand/reduce)
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015 – Research Paper Writing Help Service). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer. (For review as needed)
Chapter 9, “Anxiety Disorders”
Chapter 10, “Obsessive-Compulsive and Related Disorders”
Chapter 11, “Trauma- and Stressor-Related Disorders”
Chapter 12, “Dissociative Disorders”
Chapter 26, “Physical and Sexual Abuse of Adults”
Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (Eds.). (2015 – Research Paper Writing Help Service). Rutter’s child and adolescent psychiatry (6th ed.). Wiley Blackwell.
Chapter 26, “Psychosocial Adversity”
Chapter 27, “Resilience: Concepts, Findings, and Clinical Implications”
Chapter 29, “Child Maltreatment”
Chapter 30, Child Sexual Abuse”
Chapter 58, “Disorders of Attachment and Social engagement Related to Deprivation”
Chapter 59, “Post Traumatic Stress Disorder”
Zakhari, R. (2021). The psychiatric-mental health nurse practitioner certification review manual. Springer Publishing Company.
Chapter 6, “Physical Assessment, Diagnostic Tests, and Differential Diagnosis”
Chapter 12, “Anxiety Disorder
Required Media (click to expand/reduce)
Centers for Disease Control and Prevention. (2020, April 3). Adverse childhood experiences (ACEs) [Video].
https://www.cdc.gov/violenceprevention/aces/index.html
Dartmouth Films. (2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online, September 25). Resilience [Video]. YouTube. https://www.youtube.com/watch?v=bAXZVYDNURY
NCTSN. (2007). The promise of trauma-focused therapy for childhood sexual abuse [Video]. https://www.nctsn.org/resources/promise-trauma-focused-therapy-childhood-sexual-abuse-video
Walden University. (2021). Case study: Dev Cordoba. Walden University Blackboard. https://class.waldenu.edu
Create documentation in the Focused SOAP Note Template about your assigned patient.
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 14 (14%) – 15 (15%)
The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. 12 (12%) – 13 (13%)
The response accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. 11 (11%) – 11 (11%)
The response describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis but is somewhat vague or contains minor innacuracies. 0 (0%) – 10 (10%)
The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Or the subjective documentation is missing.
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 14 (14%) – 15 (15%)
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented. 12 (12%) – 13 (13%)
The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented. 11 (11%) – 11 (11%)
Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies. 0 (0%) – 10 (10%)
The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed. Or the objective documentation is missing.
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. Get custom essay samples and course-specific study resources via course hero homework for you service – Include pertinent positives and pertinent negatives for the specific patient case. 18 (18%) – 20 (20%)
The response thoroughly and accurately documents the results of the mental status exam.
Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected. 16 (16%) – 17 (17%)
The response accurately documents the results of the mental status exam.
Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the disorders selected. 14 (14%) – 15 (15%)
The response documents the results of the mental status exam with some vagueness or innacuracy.
Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vagueness or innacuracy. 0 (0%) – 13 (13%)
The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or the assessment documentation is missing.
In the Plan section, provide:
• Your plan for psychotherapy
• Your plan for treatment and management, including alternative therapies. Get custom essay samples and course-specific study resources via course hero homework for you service – Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
• Incorporate one health promotion activity and one patient education strategy. 23 (23%) – 25 (25%)
The response provides an evidence-based, detailed, and appropriate plan for psychotherapy for the patient.
The response provides an evidence-based, detailed, and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A strong rationale for the plan is provided that demonstrates critical thinking and content understanding.
The response includes at least one evidence-based health promotion activity and one evidence-based patient education strategy. 20 (20%) – 22 (22%)
The response provides an evidence-based and appropriate plan for psychotherapy for the patient.
The response provides an evidence-based and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. An adequate rationale for the plan is provided.
The response includes at least one health promotion activity and one patient education strategy. 18 (18%) – 19 (19%)
The response provides a somewhat vague or inaccurate plan for psychotherapy for the patient.
The response provides a somewhat vague or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is weak or general.
The response includes one health promotion activity and one patient education strategy, but it may contain some vagueness or innacuracy. 0 (0%) – 17 (17%)
The response provides an incomplete or inaccurate plan for psychotherapy for the patient.
The response provides an incomplete or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is inaccurate or missing.
The health promotion and patient education strategies are incomplete or missing.
• Reflect on this case. Ace my homework – Write my paper – Online assignment help tutors – 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 that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.). 5 (5%) – 5 (5%)
Reflections are thorough, thoughtful, and demonstrate critical thinking. 4 (4%) – 4 (4%)
Reflections demonstrate critical thinking. 3.5 (3.5%) – 3.5 (3.5%)
Reflections are somewhat general or do not demonstrate critical thinking. 0 (0%) – 3 (3%)
Reflections are incomplete, inaccurate, or missing.
Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old). 9 (9%) – 10 (10%)
The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making. 8 (8%) – 8 (8%)
The response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study. 7 (7%) – 7 (7%)
Three evidence-based resources are provided to support the assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification. 0 (0%) – 6 (6%)
Two or fewer resources are provided to support the assessment and diagnosis decisions. The resources may not be current or evidence based.
Written Expression and Formatting – The paper follows correct Ace homework tutors – APA format for parenthetical/in-text citations and reference list. 5 (5%) – 5 (5%)
Uses correct Ace homework tutors – APA format with no errors 4 (4%) – 4 (4%)
Contains 1-2 grammar, spelling, and punctuation errors 3.5 (3.5%) – 3.5 (3.5%)
Contains 3-4 grammar, spelling, and punctuation errors 0 (0%) – 3 (3%)
Contains five or more grammar, spelling, and punctuation errors that interfere with the reader’s understanding
Written Expression and Formatting – English Writing Standards:
Correct grammar, mechanics, and punctuation 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors 4 (4%) – 4 (4%)
Contains 1-2 Ace homework tutors – APA format errors 3.5 (3.5%) – 3.5 (3.5%)
Contains 3-4 Ace homework tutors – APA format errors 0 (0%) – 3 (3%)
Contains five or more Ace homework tutors – APA format errors
Total Points: 100
