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Need expert help with SOAP note formulation. Information should be in American English and utilize DSM 5 criteria. with references. Attached are the detailed for assignment
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Week 5 assignment
• Review the video, Case Study: Sherman Tremaine. 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.
Walden University. (2021). Case study: Sherman Tremaine. Walden University Canvas.
https://waldenu.instructure.com
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:
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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, and list them 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 rule 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, follow-up parameters,
and 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
evidence-based guidelines related to this case to support your diagnostics and
differential diagnoses. Be sure they are current (no more than 5 years old).
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
PRAC 6675: PMHNP Care Across the Lifespan I
Faculty Name
Assignment Due Date
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
Subjective:
CC (chief complaint):
HPI:
Substance Current Use:
Medical History:
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Current Medications:
Allergies:
Reproductive Hx:
ROS:
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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:
© 2022 Walden University
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NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
PRECEPTOR VERFICIATION:
I confirm the patient used for this assignment is a patient that was seen and managed by the student at
their Meditrek approved clinical site during this quarter course of learning.
Preceptor signature: ________________________________________________________
Date: ________________________
References
© 2022 Walden University
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