PRAC 6665 WK3 SOAP NOTE

PRAC 6665 WK3 SOAP
Assignment 2: Focused SOAP Note and Patient Case Presentation

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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 patient.
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. PRAC 6665 WK3 SOAP NOTE
Please Note:
o All SOAP notes must be signed, and each page must be initialed by your Preceptor. Note: Electronic signatures are not accepted.
o When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor.
o You must submit your SOAP note using SafeAssign. 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.
The Assignment
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).
• 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.
• 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:
o 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? PRAC 6665 WK3 SOAP NOTE
o Objective: What observations did you make during the psychiatric assessment?
o 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 diagnostic criteria and supported by the patient’s symptoms.
o Plan: What was your plan for psychotherapy? 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. Also be sure to include at least one health promotion activity and one patient education strategy.
o 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.

Learning Resources

Required Readings (click to expand/reduce)

Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
• Section II. The Psychiatric History (Chapters 14–18)
• Section III. Interviewing for Diagnosis: The Psychiatric Review of Symptoms (Chapters 23–24)

Lorberg, B., Davico, C., Martsenkovskyi, D., & Vitiello, B. (2019). Principles in using psychotropic medication in children and adolescents. In J. M. Rey & A. Martin (Eds.), IACAPAP e-textbook of child and adolescent mental health (2019 ed., pp. 1–25). International Association for Child and Adolescent Psychiatry and Allied Professions. https://iacapap.org/content/uploads/A.7-Psychopharmacology-2019.1.pdf

Meditrek
https://edu.meditrek.com/Default.html
Note: Use this link to log into Meditrek to report your clinical hours and patient encounters.

Document: Focused SOAP Note Template (Word document)

Document: Focused SOAP Note Exemplar (Word document)

CASE STUDY
A.Q 13 YEARS OLD FEMALE TO MALE, PRONOUNS ARE HE AND THEY
ADMITTED FOR SI, SIB, MAJOR DEPRESSIVE DISORDER, ADHD
MEDICATIONS ARE ADDERALL 20MG PO QAM FOR ADHD AND PROZAC 20MG PO QAM
COMPLIANT WITH MEDICATION
ALLERGIES- NONE
PATIENT FEEL MORE SECURE AND SAFE WITH FRIENDS, DON’T HAVE GOOD RAPPORT WITH MOM.
PATIENT IS EASILY TRIGGER BY MOM TELLING HER TO DO CHORES
FAMILY BACKGROUND UNKNOWN, REFUSED TO DISCUSS
POSITIVE COPING SKILLS ARE- DRAWING, HOLDING ICES, PLAYING WITH PUPPET, MUSIC, AND STRESS.
GOOD APPERTITE AND SLEEP REPORT. BOWEL MOVEMENT- DAILY
HAS SIBLINGS TWO OLDER SISTER BUT DOES NOT GET ALONG WITH THEM. PRAC 6665 WK3 SOAP NOTE