Focused SOAP Note And Patient Case Presentation
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, using the Focused SOAP Note Template provided.
· 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:
· 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 diagnostic criteria and supported by the patient’s symptoms.
· Plan: In your video, describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session?
· 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.
CASE STUDY
F.K is a 21 y/o AA male who was transferred by CPD to the ER for psychiatric evaluation due to commanding auditory hallucination and bizarre behavior. Patient stated, “I here hear voices telling me to kill my momma.” Per mom, patient has been acting bizarre at home, reported suicidal thoughts and threatened mom and others with bodily harm. Patient noted to be labile, disorganized, manic, easily agitates and also responding to internal stimuli. Patient has psychiatry history of bipolar disorder. He takes Zyprexa 10 mg PO daily but has not been compliant with his medication has reported by mom. He was just discharged from a different psychiatric hospital with DX. of acute psychosis. Patient broke up with his girlfriend about 1 month ago. His UDS is positive for Benzodiazepine and THC. Alcohol level <10. No family history of psychiatry reported. No medical history reported. No drug/food allergies reported. Per mom, patient dropped out of college in his freshman year in college.
Chief Compliant “I here hear voices telling me to kill my momma.”
