Description
In this Assignment, you use a case study to develop a focused SOAP note based on evidence-based approaches.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
TO PREPARE
Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing anxiety, obsessive compulsive, and trauma-related disorders.
Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
Review the video, Case Study: Dev Cordoba. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
Consider what history would be necessary to collect from this patient.
Consider what interview questions you would need to ask this patient.
THE ASSIGNMENT
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 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 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 priority to lowest 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.
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: What would you do differently with this patient if you could conduct the session again? Discuss what your next intervention would be if you could follow up with this patient. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), 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.).
Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).
Walden University. (2021). Case study: Dev Cordoba. Walden University Canvas. https://waldenu.instructure.com [MUSIC PLAYING] DR. JENNY: Hi there. My name is Dr. Jenny. Can you tell me yourname and how old you are? DEV CORDOBA: My name is Dev,and I am seven years old. DR. JENNY: Wonderful. Dev, can you tell me whatthe month and the date is? And where are we right now? DEV CORDOBA: Todayis St. Patrick’s Day. It’s March 17th. DR. JENNY: Do youknow where we are? DEV CORDOBA: We’reat the school. DR. JENNY: Good. Did your mom tell you whyyou’re here today to see me? DEV CORDOBA: Shethought you were going to help me be better. DR. JENNY: Yes, Iam here to help you. Have you ever come to seesomeone like me before, or talked to someone likeme before to help you with your mood? DEV CORDOBA: No, never. DR. JENNY: OK. Well, I would liketo start with getting to know you a little bitbetter, if that’s OK. What do you like to do forfun when you’re at home? DEV CORDOBA: Oh, I have a dog. His name is Sparky. We play policeman in my room. And I have LEGOs, and I couldbuild something if you want. DR. JENNY: I would love to seewhat you build with your LEGOs. Maybe you can bring thatin for me next appointment. Who lives in your home? DEV CORDOBA: My mom and mybaby brother and Sparky. DR. JENNY: Do you helpyour mom with your brother? DEV CORDOBA: No. His breath smells likebad milk all the time. [CHUCKLES] And hecries a lot, and my mom spends more time with him. DR. JENNY: So how do youfeel most of the time? Do you feel sad orworried or mad or happy? DEV CORDOBA: Worried. DR. JENNY: What types ofthings do you worry about? DEV CORDOBA: I don’tknow, just everything. I don’t know. DR. JENNY: OK. So your mom tells me you alsohave a lot of bad dreams. Can you tell me a littlemore about your bad dreams, like maybe what they’reabout, how many nights you might have them? DEV CORDOBA: I dreama lot that I’m lost, that I can’t find my momor my little brother. They seem like they happenalmost every night, but maybe not some nights. DR. JENNY: Now thatmust feel horrible. Have you ever been lost beforewhen maybe you weren’t asleep? DEV CORDOBA: Oh, no. No. And I don’t like the dark. My mom puts me in a nightlight with the door open, so I know she’s really there. DR. JENNY: That seems likethat probably would help. Do you like to go to school? Or would you rather not go? DEV CORDOBA: I worryabout by mom and brother when I’m at school. All I can think aboutis what they’re doing, and if they’re OK. And besides, nobodylikes me there. They call me Mr. Smelly. DR. JENNY: Well. That’s not nice at all. Why do you feelthey call you names? DEV CORDOBA: I don’t know. But my mom says it’s becauseI won’t take my baths. [SIGHS] She tellsme to, and it– and I have night accidents. DR. JENNY: Oh, how doesthat make you feel? DEV CORDOBA: Sad and really bad. They don’t know how it feels fortheir daddy to never come home. What if my momdoesn’t come home too? DR. JENNY: Yes, you seemto worry about that a lot. Does this worry stop you frombeing able to learn in school? DEV CORDOBA: Well, [SIGHS]my teacher is, all the time, telling me to sitdown and focus. And I get in trouble for[SIGHS] looking out the window. And she moved mychair beside her desk, but I don’t mind becauseBilly leaves me alone now. DR. JENNY: Billy. Have you ever hitBilly or anyone else? DEV CORDOBA: No, but Idid throw my book at him. DR. JENNY: Hmm. DEV CORDOBA: [CHUCKLES] DR. JENNY: What about yourself? Have you ever hit yourself orthought about doing something to hurt yourself? DEV CORDOBA: No. DR. JENNY: OK. Well, Dev, I would liketo talk to your mom now. We’re going to worktogether, and we’re going to help you feelhappier, less worried, and be able toenjoy school more. Is that OK? DEV CORDOBA: Yes. Thank you. MISS CORDOBA: Hi. DR. JENNY: Thank you, MissCordoba, for bringing in Dev. I feel we can help him. So tell me, what is yourmain concerns for Dev? MISS CORDOBA: [SIGHS] Well,he just seems so anxious and worried all the time, sillythings like I’m going to die, or I won’t pickhim up from school. He says I love hisbrother more than him. He’ll throw thingsaround the house, and gets in trouble atschool for throwing things. He has a difficulttime going to sleep. He wants his lights on, doorsopen, gets up frequently. And he’s all the timewanting to come home from school, claims stomachaches, and headaches almost daily. He won’t eat. He’s lost three poundsin the past three weeks. Our pediatrician sent us toyou because he doesn’t believe anything is physically wrong. Oh, and I almost forgot. He still wets the bed at night. [SIGHS] We’ve tried everything. His pediatriciandid give him DDVAP, but it doesn’t seem to help. DR. JENNY: Hmm. OK. Can you tell me,any blood relatives have any mental healthor substance use issues? MISS CORDOBA: No, not really. DR. JENNY: Whatabout his father? He said that he never came home? MISS CORDOBA: Oh, yes. His father was deployed withthe military when Dev was five. I told Dev he was on vacation. I didn’t know what to tell him. I thought he was tooyoung to know about war. And his father waskilled, so Dev still doesn’t understand that hisfather didn’t just leave him. [SIGHS] I just feel so guiltythat all of this is my fault. DR. JENNY: Miss Cordoba,you did the right thing by bringing in Dev. We can help you with him. MISS CORDOBA: Oh, thank you. [MUSIC PLAYING]
Unformatted Attachment Preview
NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation
Exemplar
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ
CAREFULLY
If you are struggling with the format or remembering what to include, follow the Focused
SOAP Note Evaluation Template AND the Rubric 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.
In the Subjective section, provide:
•
•
•
•
•
•
Chief complaint
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
• Allergies
• ROS
Read rating descriptions to see the grading standards!
In the 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!
In the 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 criticalthinking 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
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Exemplar
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
Subjective:
CC (chief complaint): A brief statement identifying why the patient is here. This
statement is verbatim of the patient’s 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 patient’s 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.
Or
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
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Exemplar
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.
Allergies: 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.
Reproductive Hx: 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: General: Head: 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
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Exemplar
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.
Objective:
Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to
develop the differential diagnoses (support with evidenced and guidelines).
Assessment:
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 patient’s 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 elements—DO NOT just copy the
example. You may use a preceptor’s way of organizing the information if the MSE is in
paragraph form.
He is an 8-year-old African American male 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.
Diagnostic Impression: 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
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Exemplar
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 preceptor’s 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)
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NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation
Exemplar
Client has emergency numbers: Emergency Services 911, the Client’s Crisis Line 1800-_______. 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.
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NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
Subjective:
CC (chief complaint):
HPI:
Substance Current Use:
Medical History:
•
•
•
Current Medications:
Allergies:
Reproductive Hx:
ROS:
•
•
•
•
•
•
•
•
•
•
•
•
GENERAL:
HEENT:
SKIN:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
GENITOURINARY:
NEUROLOGICAL:
MUSCULOSKELETAL:
HEMATOLOGIC:
LYMPHATICS:
ENDOCRINOLOGIC:
Objective:
Diagnostic results:
Assessment:
Mental Status Examination:
Diagnostic Impression:
Reflections:
Case Formulation and Treatment Plan:
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NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
References
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