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 fo

/ Nursing / By

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 critical-thinking 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 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 wi

Pt Name: L.G.D Age: 30 Years old.

Diagnosis: Generalized Anxiety Disorder / Insomnia / Major Depressive Disorder/ PTSD

Chief Complain: Still having panic attack. Pt is a 30 year old female, who presented to the clinic complaining that she is still having panic attack and that Fluoxetine is not helping her though it helped her to loss the weight she gained from taking Lexapro. She is having problem trying to impress people at work by trying to make them see her as a normal person which is affecting her performance. Her anxiety level is 8/10 while her depression level is 5/10. Pt denied any SI/HI/AU/VH intent. Pt uses Xanax in the morning to keep her anxiety level down and some times takes it in the afternoon. Pt’s list of medications include Alprazolam (Xanax) 1 MG Oral Tablet Fluoxetine HCl (FLUoxetine HCl) 10 MG Oral Capsule Fluoxetine HCl (FLUoxetine HCl) 20 MG Oral Capsule. Pt’s med was called in and pt is to follow up in a months time.

RESOURCES

· Carlat, D. J. (2017). 
The psychiatric interview (4th ed.). Wolters Kluwer.

· Section II. The Psychiatric History (Chapters 14–18)

· Section III. Interviewing for Diagnosis: The Psychiatric Review of Symptoms (Chapters 23–24)

· Lorberg, B., Davico, C., Martsenkovskyi, D., & Vitiello, B. (2019). 

Principles in using psychotropic medication in children and adolescents.Links to an external site.
 In J. M. Rey & A. Martin (Eds)
, IACAPAP e-textbook of child and adolescent mental health (2019 ed., pp. 1–25). International Association for Child and Adolescent Psychiatry and Allied Professions. https://iacapap.org/_Resources/Persistent/45bdffb25befc353c9f61988e82105029504ab85/A.7-Psychopharmacology-2019.1.pdf

·

MeditrekLinks to an external site.

https://edu.meditrek.com/Default.html

Note: Use this link to log into Meditrek to report your clinical hours and patient encounters.

·
Document: 

Focused SOAP Note Template


 Download Focused SOAP Note Template
(Word document)

·
Document: 

Focused SOAP Note Exemplar

[removed]

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 critical-thinking 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 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 wi Pt Name: L.G.D Age: 30 Years old. Diagnosis: Generalized Anxiety Disorder / Insomnia / Major Depressive Disorder/ PTSD Chief Complain: Still having panic attack. Pt is a 30 year old female, who presented to the clinic complaining that she is still having panic attack and that Fluoxetine is not helping her though it helped her to loss the weight she gained from taking Lexapro. She is having problem trying to impress people at work by trying to make them see her as a normal person which is affecting her performance. Her anxiety level is 8/10 while her depression level is 5/10. Pt denied any SI/HI/AU/VH intent. Pt uses Xanax in the morning to keep her anxiety level down and some times takes it in the afternoon. Pt’s list of medications include Alprazolam (Xanax) 1 MG Oral Tablet Fluoxetine HCl (FLUoxetine HCl) 10 MG Oral Capsule Fluoxetine HCl (FLUoxetine HCl) 20 MG Oral Capsule. Pt’s med was called in and pt is to follow up in a months time. RESOURCES · Carlat, D. J. (2017).  The psychiatric interview (4th ed.). Wolters Kluwer. · Section II. The Psychiatric History (Chapters 14–18) · Section III. Interviewing for Diagnosis: The Psychiatric Review of Symptoms (Chapters 23–24) · Lorberg, B., Davico, C., Martsenkovskyi, D., & Vitiello, B. (2019).  Principles in using psychotropic medication in children and adolescents.Links to an external site.  In J. M. Rey & A. Martin (Eds) , IACAPAP e-textbook of child and adolescent mental health (2019 ed., pp. 1–25). International Association for Child and Adolescent Psychiatry and Allied Professions. https://iacapap.org/_Resources/Persistent/45bdffb25befc353c9f61988e82105029504ab85/A.7-Psychopharmacology-2019.1.pdf · MeditrekLinks to an external site. https://edu.meditrek.com/Default.html Note: Use this link to log into Meditrek to report your clinical hours and patient encounters. · Document:  Focused SOAP Note Template  Download Focused SOAP Note Template (Word document) · Document:  Focused SOAP Note Exemplar [removed]

Why Choose Us

  • 100% non-plagiarized Papers
  • 24/7 /365 Service Available
  • Affordable Prices
  • Any Paper, Urgency, and Subject
  • Will complete your papers in 6 hours
  • On-time Delivery
  • Money-back and Privacy guarantees
  • Unlimited Amendments upon request
  • Satisfaction guarantee

How it Works

  • Click on the “Place Your Order” tab at the top menu or “Order Now” icon at the bottom and a new page will appear with an order form to be filled.
  • Fill in your paper’s requirements in the "PAPER DETAILS" section.
  • Fill in your paper’s academic level, deadline, and the required number of pages from the drop-down menus.
  • Click “CREATE ACCOUNT & SIGN IN” to enter your registration details and get an account with us for record-keeping and then, click on “PROCEED TO CHECKOUT” at the bottom of the page.
  • From there, the payment sections will show, follow the guided payment process and your order will be available for our writing team to work on it.