focused soap note: complex case

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xxcbyr

Health Medical

NRNP 6675

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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 child/adolescent or adult patient from your clinical experience that presents with a significant concern. Create a focused SOAP note for this patient using the template in the Resources. All SOAP notes must be signed by your Preceptor. When you submit your SOAP note, you should include the complete SOAP note as a Word document and PDF/images of completed assignment signed by your Preceptor. You must submit your SOAP Note using Turnitin.
Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.

  • Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice what you will say beforehand, and ensure that you have the appropriate lighting and equipment to record the presentation.
  • Your presentation should include objectives for your audience, at least 3 possible discussion questions/prompts for your classmates to respond to, and at least 5 scholarly resources to support your diagnostic reasoning and treatment plan.

Video assignment for this week’s presenters:

Record yourself presenting the complex case study for your clinical patient. In your presentation:

  • Dress professionally and present yourself in a professional manner.
  • Display your photo ID at the start of the video when you introduce yourself.

Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).

State objectives for the presentation that are targeted, clear, use appropriate verbs from Bloom’s taxonomy, and address what the audience will know or be able to do after viewing.

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.

Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value. 

Pose three questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.

  • 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.
  • 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: 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 with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms.

Plan: What was your plan for psychotherapy (include one health promotion activity and patient education)? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.  Discuss an identified social determinate of health impacting this patient’s mental health status and provide your recommendation for a referral to assist this patient in meeting this identified need (students will need to conduct research on this topic both in the literature and for community resources).

  • Reflection notes: What would you do differently with this patient if you could conduct the session again? 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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NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template Patient initial: Age: Gender: Race: 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: © 2021 Walden University Page 1 of 2 NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template References © 2021 Walden University Page 2 of 2
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Explanation & Answer

Attached.

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template

Focused Soap Note, Complex Case.

Name
Institution
Course
Tutor
Date

© 2021 Walden University

Page 1 of 6

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
Patient initial: A.T Age: 29-years-old Gender: F

Race: African American

Subjective:
CC (chief complaint): “I am not leaving a peaceful and feels unwell”
HPI: Mrs A.T. is a 29-year-old African American female patient who visits the clinic for a
mental evaluation. Since the delivery of her four-month-old child, she has not been
feeling well and has reported facing the challenge of adapting to a new life of having a
newborn. She was facing the challenge of caring for the child and reported being
overwhelmed. She recognizes sleeping difficulties, and this indicates the challenge of
resting following delivery, especially when the baby cries. She denies hunger or despair
regarding her body appearance or size. She admits the unfortunate confidence and the
increased feelings of insufficiency. Mrs. A.T. craves to keep away from social
communication, and she reports being upset about everything and easily getting furious.
She admits to having lost interest in the activities she previously enjoyed, such as
writing. She acknowledges having suicidal thoughts but received no medication or
remedy. She admits not to be prepared to injure her child but is not on any psychiatric
medications.
Substance Current Use: she report no use of illegal substance or drinking alcohol.
Medical History: she has been diagnosed with hypertension.




Current Medications: she is non-adherence to the hypertension medication
(Trandate 100 mg). Her non-adherence to the medication is due to her
forgetfulness.
Allergies: admits to be allergic to penicillin.
Reproductive Hx: the patient is presently nursing her four months new born
baby and is not currently on any birth control. She reports no engagement in
sexual activities...


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Great study resource, helped me a lot.

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