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Name:
DOB:
Minor:
Accompanied by:
Demographic:
Gender Identifier Note:
Chief Complaint
Reason for the visit, often in the patient’s words
History of Present Illness
Subjective information from the patient.
Description of what the patient wants to be seen for
Mood characteristics
Depression/Anxiety/Panic/Mood instability, etc
Tolerable/Not tolerable
Getting worse or better, if so when did this start
Any stressors that make the condition worse
Are the stressors internal or environmental
When did the patient start manifesting the mood characteristics
Pertinent past history if it pertains to current condition, but it should really only include what is currently
happening with the patient.
Things that are exacerbating or alleviating symptoms
SI/HI
Include if the thoughts are passive or active
Intent
Plan
Access to what is needed to complete plan
If HI, do they have a target (consider duty to warn)
Hallucinations/Delusions
If having, what type
How long is it happening
If causing distress
Sleep
Trouble falling asleep
Staying Asleep
Daytime fatigue
Medications
Current medications related to current issue (Prescription, OTC, Supplements)
Side Effects
Effectiveness
Appetite
If patient has multiple issues, what does the patient view as the priority issue to manage
Are they seeing a therapist or any other resource for their current condition
Psychiatric History:
Age of onset
Previous Diagnoses
Past psychotropic history
Past Hospitalizations
Reason for hospitalization
Include dates
Length of stay
Suicide Attempt History
Dates
What they did to attempt
What triggered the attempt
Legal History
Dates
What arrested or in jail for
Trauma History
Physical, Emotional, Sexual or Event
What was the trauma
When did happen
Who performed the abuse if applicable
If they have dealt with the trauma
Substance Use History
Include Past and Present Use
Tobacco
Alcohol
Marijuana
Illicit Substance (ask what substances specifically)
Ask if this has been a problem for the patient in the past and how they have coped with it if they quit
Can also include caffeine if want to
Social History
Include
Born and Raised
Parents married, divorced, separated
Siblings
Childhood (developmental, emotional)
Highest level of education
Employment status (if unemployed, is patient looking for a job)
Relationship status
Children
Living Situation
Social Support
Medical History
Surgical History
Current Medications (All Medications, even if not psychotropics)
Allergies
Family History (Medical and Mental Health)
Review of Systems
OBJECTIVE
Vital signs
Labs
Test results e.g EKGs
Mental Status Exam
Assessment
Screening Tool results if any used
Risk Assessment
Diagnoses (Justify diagnosis and differential diagnosis using DSM -5)
Current
Rule Out
Differential
Plan of Care (This section should be very detailed. I will place an example here. You can modify as you
see fit)
The patient denies suicidal or homicidal ideation including intention, method or plan. There are no other
safety concerns. This individual is appropriate to be followed in the outpatient clinic. The writer reviewed
all of the intake forms as well as the mental health screens. This individual did sign consent forms for
treatment as well as the privacy and financial policies.
Regarding medications, medications were discussed in depth at this appointment. We will continue
Lexapro 20mg daily for depression and anxiety. We will initiate Abilify 2mg daily at bedtime to augment
Lexapro and help with treatment resistant depression, propranolol 10mg TID PRN for anxiety. If patient
does not receive relief with Abilify alone, we may consider switching to Effexor at next appointment and
cross-titrating with Lexapro. Patient agreed to cut back on drinking, but if continues to have issues with
drinking will discuss treatment strategies at next appointment. Risk, Benefits and alternatives regarding
medications were discussed with the patient and patient is agreeable to treatment plan. Medications
prescribed through ePrescribing.
Writer discussed the importance of psychotherapy related to treatment, patient was referred to an
onsite therapist for psychotherapy and CBT.
Patient was instructed to exercise regularly, utilize sleep hygiene, avoid alcohol, illicit substances, and
caffeine. Patient advised to practice mindfulness strategies
Writer is recommending patient continue to follow-up with PCP regarding any medical conditions
Patient advised to call 911 or report to emergency room if there is a medical or mental health emergency
Recommend that patient follow-up in 2 weeks
Additional resources were provided to this patient to include handouts with some basic coping skills for
when the patient has anxiety, sleep hygiene practices and information on the therapies recommended.
Labs were also ordered at this appointment to include a CBC with Diff, CMP, Lipids, Vitamin B12, Vitamin
D, Hemoglobin A1C. May consider additional labs to include UDS, GGT level, Iron Panel if hemoglobin
low
Discussions of FDA-approved medications or indication of “off-label” usage are important for treatment
plans.
For females, discussion on the effects medication has on birth control, pregnancy, and sexual dysfunction
For males, discussion on sexual dysfunction
Under 25 years old Black box warning for SSRI/SNRI
Billing Codes
Time Spent with patient, therapy time, date
Your name and title
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•
Unit 8: Assignment Clinical SOAP Note
Immersive Reader
Each week students will choose one patient encounter to submit a Follow-up SOAP note
for review.
Follow the rubric to develop your SOAP notes for this term.
The focus is on your ability to integrate your subjective and objective information
gathering into formulation of diagnoses and development of patient-centered, evidencebased plans of care for patients of all ages with multiple, complex mental health
conditions. At the end of this term, your SOAP notes will have demonstrated your
knowledge of evidence-based practice, clinical expertise, and patient/family preferences
as expected for an independent nurse practitioner incorporating psychotherapy into
practice.
Note: Grades of Incomplete on this assignment will result in a clinical failure.
Upload note to TurnItIn plagiarism checker for grade submission.
All work should be original and submitted as a Word document unless otherwise indicated
in the assignment instructions. ALL assignments need to be APA 7 format and
accompanied title page in APA 7th edition format in order that the work would be properly
identified for the student, the course, and the assignment. Work submitted without a title
page will receive a grade of 0.
Complete this assignment and submit it to this assignment dropbox by Sunday at 11:59
pm CT.
Estimated time to complete: 2 hours
Rubric
NU675 Unit 8 Assignment – Clinical: SOAP Note
NU675 Unit 8 Assignment – Clinical: SOAP Note
Criteria
This criterion is
linked to a Learning
OutcomeSubjective
Information
This criterion is
linked to a Learning
OutcomeObjective
Information
This criterion is
linked to a Learning
OutcomeAssessment:
Problem
Identification and
Prioritization
Ratings
3 pts
Level 5
Complete and
concise summary
of pertinent
information.
2 pts
Level 3
Well organized;
partial but accurate
summary of pertinent
information (>80%).
1 pts
Level 1
Poorly organized and/or
limited summary of
pertinent information
(50%-80%); information
other than “S” provided.
0 pts
Level 0
Less than 50% of
pertinent information is
addressed; or is grossly
incomplete and/or
inaccurate.
3 pts
Level 5
Complete and
concise summary
of pertinent
information.
2 pts
Level 3
Partial but accurate
summary of
pertinent
information
(>80%).
1 pts
Level 1
Poorly organized and/or
limited summary of
pertinent information (50%80%); information other
than “O” provided.
0 pts
Level 0
Less than 50% of
pertinent information is
addressed; or is grossly
incomplete and/or
inaccurate.
2 pts
Level 5
Complete problem
list generated and
rationally
prioritized; no
extraneous
information or
issues listed.
1.33 pts
Level 3
Most problems are
identified and
rationally
prioritized,
including the
“main” problem for
the case (>80%).
0.67 pts
Level 1
Some problems are
identified (50%-80%);
incomplete or inappropriate
problem prioritization;
includes nonexistent
problems or extraneous
information included.
0 pts
Level 0
Less than 50% of
problems are listed; or
main problem missed;
or problems not
prioritized and/or
identified nonexistent
problems.
NU675 Unit 8 Assignment – Clinical: SOAP Note
Criteria
This criterion is
linked to a Learning
OutcomeAssessment:
Assessment of
Current Psychiatric
& Medical
Condition(s) or Drug
Therapy-related
Problem
This criterion is
linked to a Learning
OutcomeAssessment:
Treatment Goals
This criterion is
linked to a Learning
OutcomePlan:
Treatment Plan
Ratings
2 pts
Level 5
An optimal and
thorough assessment is
present for each
problem.
1.33 pts
Level 3
An assessment is
present for each
problem listed but not
optimal.
0.67 pts
Level 1
Assessment is
present for 50-80%
of problems
0 pts
Level 0
Less than 50% of
problems include an
appropriate assessment.
2 pts
Level 5
Appropriate and
relevant therapeutic
goals for each
identified problem.
1.33 pts
Level 3
Appropriate
therapeutic goals for
most identified
problems (>80%).
0.67 pts
Level 1
Appropriate therapeutic
goals for a few
identified problems
(50%-80%).
0 pts
Level 0
Less than 50% of
problems have
appropriate
therapeutic goals.
2 pts
Level 5
Specific, appropriate and
justified recommendations
(including drug name, strength,
route, frequency, and duration
of therapy) for each identified
problem.
1.33 pts
Level 3
Mostly complete
and appropriate
for each
identified
problem (>80%).
0.67 pts
Level 1
Partially complete
and/or inappropriate for
a few identified
problems (50%-80%);
information other than
“P” provided.
0 pts
Level 0
Less than 50% of
problems have an
appropriate and
complete
treatment plan.
NU675 Unit 8 Assignment – Clinical: SOAP Note
Criteria
This criterion is
linked to a Learning
OutcomePlan:
Counseling, Referral,
Monitoring &
Follow-up
Total Points: 15
Ratings
1 pts
Level 5
Specific patient
education points,
monitoring parameters,
follow-up plan and
(where applicable)
referral plan for each
identified problem.
0.5 pts
Level 3
Patient education
points, monitoring
parameters, follow-up
plan and referral plan
(where applicable) for
>80% of identified
problems.
0.25 pts
Level 1
Patient education
points, monitoring
parameters, follow-up
plan and referral plan
(where applicable) for a
few identified problems
(50%-80%).
0 pts
Level 0
Less than 50% of
problems include
appropriate
counseling,
monitoring, referral
and/or follow-up
plan.
Subjective
The patient reports that her grandfather is currently in hospice care, which has caused her to return
home. She mentions that her suicidal ideations have improved and believes they may be related to
hormonal fluctuations, possibly due to premenstrual dysphoric disorder (PMDD). She plans to discuss
this with her gynecologist and consider a different type of birth control.
The patient has not had a period since her last visit and has been experiencing frequent headaches. She
is unsure if the headaches are related to the increased dosage of Prozac. She has discontinued Trazodone
due to excessive grogginess and impaired functioning. The patient is also working with a neurologist to
manage her migraines and has increased her preventative medication, Zonisamide. She plans to restart
Botox treatment for her migraines.
The patient reports difficulty sleeping and prefers to use melatonin over Trazodone. She is currently
taking 5 milligrams of melatonin but is not sleeping well and has difficulty shutting her brain off. She has
tried Mirtazapine (Remeron) in the past but experienced significant weight gain and has a history of an
eating disorder. The patient estimates that she has difficulty sleeping six out of seven nights per week,
which negatively impacts her mental health.
Objective
BP: 132/81
HR: 76
RR: 17
SPO2: 99%
ASSESSMENT AND PLAN
1. Suicidal Ideations and PMDD
– Patient notes an improvement in suicidal ideations, with a suspicion of hormonal influences.
– Plan: Maintain ongoing monitoring, and encourage the patient to explore birth control options with
their gynecologist.
2. Depression
– Patient is currently taking Prozac and finds it beneficial.
– Plan: Switch Prozac from 40 mg to 20 mg twice daily, and instruct the patient to observe any changes in
headache symptoms.
3. Headaches
– Patient reports frequent headaches, uncertain of their relation to Prozac.
– Plan: Observe headache frequency and intensity following the Prozac dosage change, continue
collaboration with the neurologist, maintain Zonisamide regimen, and reinstitute Botox treatment for
migraines.
4. Insomnia
– Patient has ceased Trazodone use due to experiencing grogginess, and is now using melatonin with
limited success.
– Plan: Discontinue Trazodone, initiate Lunesta 1 mg as needed for sleep, and monitor for both
effectiveness and potential dependency.
5. Anxiety
– Patient describes challenges with calming their mind at night.
– Plan: Continue to assess anxiety levels and consider potential treatment modifications as necessary.
Follow-up Appointment
– A follow-up appointment is scheduled for Monday, March 13th at 7:00 PM to evaluate the efficacy of
the current treatments and to discuss any required adjustments.
Instructions
You will create 7 entries for your Reflective Journal about a patient encounter. In the 7th
entry, you will review the previous 6 entries and evaluate your progress in reflective
practice over the course of the term. Each journal should be a minimum of 250 words.
The purpose of this reflective journal is self-reflection regarding the role in the process of
self-reflection as a PMHNP provider. Through reflective practice, the student will
evaluate their own emotional health and recognize one’s own feelings as well as one’s
ability to monitor and manage those feelings. The point of the exercise is to learn yourself,
your triggers, the types of cases you end up getting overly involved with, and those you’d
rather refer to someone else. The idea is to be able to personally reflect on your
behaviors/thoughts/decisions and how those impact you in the role of PMHNP.
Address the Following Items:
•
•
Compare and contrast methadone and buprenorphine. Include mechanism of action,
and pros/cons.
Do you plan or have a desire to work with substance use disorders in an in-depth
fashion.
Use the appropriate APA formatting with a minimum of 2 references to support your
work.
All components must be discussed to receive full credit as complete.
•
•
All work should be original and submitted as a Word document unless otherwise
indicated in the assignment instructions
All work should be accompanied by a title page and reference page in APA 7thedition
format. Work submitted without a title page will receive a grade of zero.
Note: Grades of Incomplete on this assignment will result in a clinical failure.
Complete this assignment and submit it to this assignment dropbox by Sunday at 11:59
pm CT.
Estimated time to complete: 2 hours
Rubric
NU675 Unit 8 Assignment – Clinical: Journal Reflection
NU675 Unit 8 Assignment – Clinical: Journal Reflection
Criteria
This criterion is
linked to a
Learning
OutcomeContent
Reflection
Ratings
8 pts
Level 5
Reflection demonstrates a
high degree of critical
thinking in applying,
analyzing, and evaluating
key course concepts and
theories from readings,
lectures, media, discussions
activities, and/or
assignments. Insightful and
relevant connections made
through contextual
explanations, inferences,
and examples.
5.6 pts
Level 3
Reflection demonstrates
some degree of critical
thinking in applying,
analyzing, and/or
evaluating key course
concepts and theories
from readings, lectures,
media, discussions
activities, and/or
assignments. Connections
made through
explanations, inferences,
and/or examples.
3.2 pts
Level 1
Reflection demonstrates
limited critical thinking in
applying, analyzing,
and/or evaluating key
course concepts and
theories from readings,
lectures, media,
discussions, activities,
and/or assignments
Minimal connections
made through
explanations, inferences,
and/or examples.
0 pts
Level 0
Reflection lac
critical thinki
Superficial
connections a
made with ke
course concep
and course
materials,
activities, and
assignments.
NU675 Unit 8 Assignment – Clinical: Journal Reflection
Criteria
This criterion is
linked to a
Learning
OutcomePersonal
Growth
This criterion is
linked to a
Learning
OutcomeTimliness
Total Points: 20
PreviousNext
Ratings
8 pts
Level 5
Conveys strong evidence
of reflection on own work
with a personal response
to the self-assessment
questions posed.
Demonstrates significant
personal growth and
awareness of deeper
meaning through
inferences made,
examples, well developed
insights, and substantial
depth in perceptions and
challenges. Synthesizes
current experience into
future implications.
4 pts
Level 5
Journal reflection is
submitted on or
before deadline.
5.6 pts
Level 3
Conveys evidence of
reflection on own work
with a personal
response to the selfassessment questions
posed. Demonstrates
satisfactory personal
growth and awareness
through some
inferences made,
examples, insights, and
challenges. Some
thought of the future
implications of current
experience.
2.8 pts
Level 3
Journal reflection is
submitted within 1 day
(24 hours) after the
deadline.
3.2 pts
Level 1
Conveys limited
evidence of reflection on
own work in response to
the self-assessment
questions posed.
Demonstrates less than
adequate personal growth
and awareness through
few or simplistic
inferences made,
examples, insights,
and/or challenges that are
not well developed.
Minimal thought of the
future implications of
current experience.
0 pts
Level 0
Conveys inadequat
evidence of reflecti
own work in respon
the self-assessment
questions posed.
Personal growth an
awareness are not
evident and/or
demonstrates a neu
experience with
negligible personal
impact. Lacks enou
inferences, exampl
personal insights an
challenges, and/or
implications are
overlooked.
1.6 pts
Leve 1
Journal reflection is
submitted 1-2 days (25-48
hours) after the deadline.
0 pts
Level 0
Journal reflection is
submitted 2-3 days (
hours) after the dead
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