Create a Focused SOAP Note on this patient using the template provided in the Learning Resources.
Assignment 2: Focused
SOAP Note and Patient Case Presentation
Photo Credit: Pexels
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
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.
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.
All SOAP notes must be
signed, and each page must be initialed by your Preceptor. Note: Electronic
signatures are not accepted.
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.
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
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
Ensure that you have the
appropriate lighting and equipment to record the presentation.
presenting the complex case for your clinical patient.
Do not sit and read
your written evaluation! The video portion of
the assignment is a simulation to demonstrate your ability to succinctly
and effectively present a complex case to a colleague for a case consultation.
The written portion of this assignment is a simulation for you to demonstrate
to the faculty your ability to document the complex case as you would in an
electronic medical record. The written portion of the assignment will be
used as a guide for faculty to review your video to determine if you are
omitting pertinent information or including non-essential information during
your case staffing consultation video.
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
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
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?
In your written plan
include all the above as well as include one 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 one health
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