SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.
S = Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS)
O = Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam, (Focused), and Mental Status Exam
A = Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes
P = Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up
Other: Incorporate current clinical guidelines NIH Clinical GuidelinesLinks to an external site. or Ace homework tutors – APA Clinical GuidelinesLinks to an external site., research articles, and the role of the PMHNP in your video presentation.
Reminder: It is important that you complete this assessment using your critical thinking skills. You are expected to synthesize your clinical assessment, formulate a psychiatric diagnosis, and develop a treatment plan independently. It is not acceptable to document “my preceptor made this diagnosis.” An example of the appropriate descriptors of the clinical evaluation is listed below. It is not acceptable to document “within normal limits.”
1. Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.
2. Upload your completed comprehensive psychiatric evaluation as a Word doc.
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Comprehensive Psychiatric Evaluation
Patient Information:
Name: [Patient’s Name]
Date of Birth: [Patient’s Date of Birth]
Gender: [Patient’s Gender]
Date of Evaluation: [Date of Evaluation]
Reason for Evaluation:
The patient presented to the clinic with the following chief complaint: “Feeling sad, hopeless, and lacking interest in activities.” The history of the present illness (HPI) reveals that the patient has been experiencing these symptoms for the past six months. The symptoms are characterized by a persistent low mood, loss of interest or pleasure in activities, significant weight loss, difficulty sleeping, psychomotor agitation, fatigue, feelings of worthlessness or guilt, diminished ability to think or concentrate, and recurrent thoughts of death or suicidal ideation. These symptoms have caused significant distress and impairment in the patient’s daily functioning.
Review of Systems (ROS):
The patient denies any significant symptoms in other body systems.
Objective Data:
Medications: None
Allergies: No known allergies
Past Medical History: No significant medical conditions
Family Psychiatric History: Family history of major depressive disorder in the patient’s mother
Past Surgical History: No past surgical history
Psychiatric History: No previous psychiatric diagnoses, treatment, or hospitalizations
Social History: The patient is employed and lives alone. Limited social support.
Labs and Screening Tools: Complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid-stimulating hormone (TSH), and urine drug screen within normal limits.
Vital Signs: Blood pressure 120/80 mmHg, heart rate 80 bpm, respiratory rate 16 bpm, temperature 36.8°C
Physical Exam: Unremarkable
Mental Status Exam: The patient appears sad, with a constricted affect. Speech is slow and low in volume. The patient demonstrates impaired concentration and exhibits feelings of guilt and worthlessness. Recurrent thoughts of death are present.
Assessment:
Based on the information gathered from the psychiatric evaluation and in accordance with the current clinical guidelines, the following assessment is made:
Primary Diagnosis: Major Depressive Disorder (MDD), single episode, severe without psychotic features
ICD-10 code: F32.2
DSM-5 code: 296.22
Differential Diagnoses:
Persistent Depressive Disorder (Dysthymia) – ICD-10 code: F34.1, DSM-5 code: 300.4
Adjustment Disorder with Depressed Mood – ICD-10 code: F43.21, DSM-5 code: 309.0
Plan:
The treatment plan for the patient will involve both pharmacologic and non-pharmacologic interventions. The specific components of the plan include:
Pharmacologic Treatment:
Selective serotonin reuptake inhibitor (SSRI) antidepressant medication, such as escitalopram, starting at a low dose and titrating as tolerated.
Regular monitoring of medication response and side effects.
Psychoeducation regarding the importance of adherence to medication and potential side effects.
Non-Pharmacologic Treatment:
Cognitive-behavioral therapy (CBT) to address negative thought patterns, enhance coping skills, and promote behavior activation.
Encouraging regular exercise, maintaining a balanced diet, and ensuring adequate sleep hygiene.
Psychoeducation regarding stress management techniques and relaxation exercises.
Diagnostic Testing/Screening Tools:
The Patient Health Questionnaire-9 (PHQ-9) to assess the severity of depressive symptoms and monitor treatment response over time.
Patient/Family Teaching:
Educate the patient and their family about the nature of Major Depressive Disorder, its course, and the importance of treatment adherence.
Provide information on recognizing warning signs of worsening depression or suicidal ideation and the appropriate steps to take in such situations.
Encourage involvement of supportive family members or friends in the patient’s treatment and recovery.
Referral:
Refer the patient to a psychotherapist for ongoing CBT sessions.
Consultation with a psychiatrist for further evaluation and consideration of adjunctive or alternative pharmacotherapy if necessary.
Follow-up:
Schedule weekly follow-up appointments for the first month to monitor treatment response, side effects, and suicidal ideation.
Adjust the treatment plan as needed based on the patient’s progress and ongoing evaluation.
Transition to monthly follow-up appointments once the patient’s symptoms improve and stabilize.
Role of the PMHNP:
As the Psychiatric-Mental Health Nurse Practitioner (PMHNP), my role in this patient’s care involves conducting a comprehensive psychiatric evaluation, formulating a diagnosis of Major Depressive Disorder, and developing an individualized treatment plan. I will apply current clinical guidelines, such as the NIH or Ace homework tutors – APA Clinical Guidelines, to ensure evidence-based practice and provide the highest standard of care. I will also incorporate research articles and ongoing professional development to stay up-to-date with the latest advancements in psychiatric care. As part of the interdisciplinary team, I will collaborate with other healthcare providers, including psychotherapists and psychiatrists, to optimize the patient’s outcomes and provide ongoing support throughout their treatment journey.
