- Review the Focused SOAP Note template, (NRNP PRAC 6675 Focused SOAP Note Template.doc) which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
- Select a child/adolescent patient from your clinical experience that presents with significant concern. Create a focused SOAP note for this patient using the template in the Resources. You must submit your SOAP note using Turnitin
- Your presentation should include objectives for your audience, three possible discussion questions and three prompts for your classmates to respond to, and at least five scholarly resources to support your diagnostic reasoning and treatment plan.
Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:
- Subjective: What details did the patient provide regarding their chief complaint and symptomatology 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 the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5 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.
- Plan: What is your plan for psychotherapy? What is 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 incorporate one health promotion activity and one patient education strategy.
- Reflection notes: Reflect on this case. 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 that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
- Your presentation should include objectives for your audience, three possible discussion questions and three prompts for your classmates to respond to, and at least five scholarly resources to support your diagnostic reasoning and treatment plan.
CASE STUDY: Chief complaint: “Feeling much better than the last visit”
Type of visit: Psychotropic Medication Session
Diagnosis: MDD
HPI: CH is an 11-year-old Caucasian female who reports feeling much better than the last visit from depression after her parents got a divorce last year. She reports her eating habit is slowly coming back and she has started slowly going back to school. She reports that it’s been hard but she is improving. She denies Suicidal ideation and auditory or visual hallucination or any form of abuse. Recommends continuing Cognitive Behavioral Therapy. P: continue with Prozac 10mg PO QD. A follow-up visit in 6 weeks.
SAMPLE UPLOADED: 6645 NRNP and PRAC Comprehensive Psychiatric Evaluation Template-2.doc
- COPY AND PASTE ON GOOGLE SEARCH AND DOWNLOAD TEXTBOOK: http://library.lol/main B508EB9143CF6197AD8493708ADDDEA3
- Sadock, B. J., Sadock, V. A., and Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer. Chapter 8, “Mood Disorders”
Zakhari, R. (2020).