Please review the complete instructions and use the attached word document to complete the assignment.
NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATEREAD CAREFULLY
If you are struggling with the format or remembering what to include, follow the
Focused SOAP Note Evaluation Template
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.
Subjective section, provide:
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
Read rating descriptions to see the grading standards!
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!
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. Include pertinent positives and pertinent negatives for the specific patient case
Read rating descriptions to see the grading standards!
Reflect on this case. Include: 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
CC (chief complaint): A
brief statement identifying why the patient is here. This statement is verbatim of the patients 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 patients 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.
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. 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.
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.
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:
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.
Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
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 patients 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 elementsDO NOT just copy the example. You may use a preceptors way of organizing the information if the MSE is in paragraph form.
He is an 8-year-old African Americanmale 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.
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. 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 preceptors 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)
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 formatting.
2022 Walden University Page 1 of 3 [removed] CASE STUDY:
Female, 15, separation anxiety disorder, Depression
The patient is a fifteen-year-old female teenager who presents to the clinic with her mother for her first assessment. Patient is being referral to the clinic by the school counselor due to low grades and poor school assistance. During the session, both the patient and the mother are neatly dressed. Her mother seems to be worried about her daughter. The patient said, “I worry a lot about my family members. I fear that one day my parents will be abducted or fatally injured. The worries and fears make me have difficulties concentrating on personal well-being and my studies in school.” The mental assessment shows that the patient is depressed, and she refuses to leave the proximity of her mother. Her mother says that her daughter has been experiencing depression or anxiety attacks. The physical assessment shows that the patient has been experiencing physical aches and pains. She maintains good eye contact. Her mood is a little anxious. The symptoms conclude that the patient has separation anxiety disorder because the symptoms have progressed for the past six months. Treatments include antidepressants, group therapy, family therapy, dialectical behavioral therapy, and cognitive-behavioral therapy. A follow-up is to be done in two weeks.
Assignment 2: Focused SOAP Note and Patient Case Presentation
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, usingthe Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.
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.
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-5diagnostic criteria and supported by the patients symptoms.
Plan:In your video, describeyour treatmentplan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatmentsavailable and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What wereyourfollow-up plan and parameters? What referrals would you make or recommend as a result of this treatmentsession?
In your written plan include all the above as well asincludeone social determinant of health according to the HealthyPeople 2030 (you will need to research)as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are onehealth promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
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.
At least 3 references
Review the Exemplar as a guide to complete the assignment, and.
Usethe Focused SOAP Note Template provided to complete the assignment.
Sally calls about an urgent issue with her catering company contract with the federal government. Her usual supplier was hospitalized and could not ship her weekly order to service her military accounts. General Messhall told Sally to contact a different supplier to fill the order. Sally faxed her standard pre-printed order form to the new supplier for $17,642.54 worth of goods. The order form contained the foodstuff, quantity, payment terms, the amount listed on the front, and the usual boilerplate terms on the back. Within two days, Sally received the order from the substitute supplier. The supplier also sent his pre-printed invoice form with the supply delivered on the front and different boilerplate terms than Sally’s invoice on the back that also contained a payment term penalty. Jack’s business form included a price of $20,642.54, a three-thousand-dollar price increase over Sally’s invoice. When Sally received the goods the next day, she immediately put them in cold storage. That same day Sally received a call from someone who identified himself as “Jack, the Substitute Supplier.” Jack stated, “Hey! This is Jack, the Substitute Supplier. I want to inform you that your payment for the shipment is overdue, and because you’re late, the rate is an additional $3,000 per day plus the base price.” Sally said Jack told her to review his invoice which stated that a penalty of $3,000 per 12 hours default nonpayment surcharge attaches for late payments.
Sally retorts, “Yeah, well, I don’t accept.” She instantly retrieved his invoice, read the terms on the back of the invoice, and realized that the supplier’s form had payment terms demanding payment for delivery of goods within 12 hours of delivery. That calculated out to be $6,000 over her regular invoice price and another $3,000 due in 12 hours. Sally noted that her form had a different term for payment that gave her 30 days net payment. Jack, the substitute supplier, told Sally before hanging up that if he doesn’t receive his cash, plus any penalties due, Jack would immediately file a lawsuit for breach of the terms of his delivery order.
Sally retrieves her form and compares the two order forms side by side. She notes a substantial difference in the boilerplate terms but notes other conditions are similar but noticeably different enough to make the effect substantially unfavorable to her. Jack’s form matched the goods requested, listed the correct quantity, and the delivery terms were the same as her form required. Jack’s standard terms (often called “boilerplate”) were utterly unreasonable and one-sided, not matching hers at all. He had the right to substitute non-conforming goods and did not warrant the quality of the products. Jack’s PO stated that if a dispute arose between the PO’s terms, the merchants must pursue resolution through Alternative Dispute Resolution (ADR), mandated arbitration. Jack’s PO also stated that if the dispute involved interpreting a price term, Jack could sue in Federal Court in his state based on Diversity of Citizenship. Since the issue involved pricing, Jack could file a suit immediately.
Between merchants, it is customary to use purchase and acceptance order forms for commercial transactions involving the sale of goods without a negotiated signed contract. PO’s are standard printed forms that contain boilerplate terms and a few essential terms directed at commercial goods. They are fast and easy to use and designed to cover essential information and requirements of merchants. Contracts take time, and the process does not always result in an agreement, nor are contracts completed on time once the lawyers are involved. With merchants, time is of the essence; they need it now! While written by a lawyer, purchase orders do not have transactional legal oversight, especially when crossing PO’s, one from merchant buyer and one from merchant seller. As a result, the merchants don’t end up with signed contracts. The question is, at what point is a contract formed, if at all, and what are the terms? PO disputes continuously end up in litigation. These cases are very fact-specific, resulting in the specific transaction in question. The ultimate issue with competing PO forms with different essential terms is what’s enforceable considering the content of both forms.
Sally believes she is in the right because it was her order and invoice. She states she never agreed to the terms of his invoice nor accepted the goods. It appears Jack has agreed to her terms because he sent the supplies. His demands are troubling because he added unacceptable pricing terms.
Based on Sally’s information, prepare an IRAC formatted response outlining the issues and answering the questions below within the IRAC analysis form (DOCX
analysis form (DOCX).
What are the elements needed to form a contract?
Is an agreement to meet in the park at noon enforceable? Why? Why not?
What is a Purchase Order?
How would you characterize the terms of a Purchase Order?
Is there a difference between a purchase order (invoice) and a contract? If so, compare the two instruments and outline the difference between the two. Please outline the advantages and disadvantages of each.
Are purchase orders controlled under contract law or the Uniform Commercial Code (UCC), or both?
How many transactions are there under the UCC case study facts, one or two? Explain?
How or when is an enforceable agreement formed in contract negotiations? At what point, with a purchase order (invoices), is an enforceable agreement established under the UCC? Is there a binding agreement in the Sally/Jack case? Why or why not?
What facts are in Sally’s favor of canceling the order? List them supported by the facts and the applicable statutory sections.
What facts are in Jack’s favor in enforcing payment? What sections of the UCC support Jack’s arguments?
In contract law, you must have a “meeting of the minds” as part of an enforceable agreement. Another element requires that the acceptance must match the offer. What is this contract rule called?
Common law contracts require that acceptance must not add or change any terms of the offer. What is it called when an acceptance of an offer changes terms of the offer?
In the Sally/Jack case, is there a “meeting of the minds” under the UCC when the merchants use invoices that differ in terms? Explain why or why not. What UCC sections support your answer? List the code sections and summarize applicable parts.
Have Sally and Jack formed a contract under the facts? If so, what terms are enforceable, and what UCC sections support your answers? How should this dispute be resolved?
Which facts and code sections would support the position that Sally did not accept the goods? List the facts and summarize the applicable code sections.
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