- 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 their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms.
- Plan: What was your plan for psychotherapy (include one health promotion activity and patient education)? What was 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. Discuss an identified social determinate of health impacting this patient’s mental health status and provide your recommendation for a referral to assist this patient in meeting this identified need (students will need to conduct research on this topic both in the literature and for community resources).
- Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow-up, discuss what your next intervention would be.
Scenario Note
Age: 14 years Sex: Female DOB: 1/21/2009
CAAP Admission Note
Chief Complaint
Patient: "I'm not suicidal"
Parent: "CAT team wants her to go to residential"
HPI
Quality: self injurious behavior/anxiety
Duration: months
Timing: acute on chronic
Severity: severe, interfering with safety of self
Context: precipitating stressor for admission partial response to medications
Modifying factors: medications, therapeutic milieu
Associated signs and symptoms: see HPI & MSE
HPI: Patient is a 14yo female with a prior psychiatric history of mood disorder who self-presents to crisis accompanied by her father for evaluation.
Upon interviewing today, patient is withdrawn, anxious appearing, thought process is linear and logical, thought content centered on her self-harm "I feel a bunch of emotions before I am doing it – I can be sad, I can be happy". Patient reports that in the last week her self-injurious behavior (cutting) has intensified. Patient has a superficial laceration on her neck, multiple lacerations on arms (she reports she uses glass). No intent to kill herself. Patient reports high anxiety levels. DFA. Patient compliant to her medication regime (zoloft 150mg, abilify 10mg, hydroxyzine as needed for anxiety). Patient stayed for 35 days in residential tx (she was discharged on 2nd September) – she does not want to go back. Pt started psychotherapy 5 months ago. Has an outpatient psychiatrist back in Key West.
Per patient:
Pt calm cooperative and pleasant during interview, and because she "knows what questions we are going to ask, immediately states "I just want to say, I am not suicidal!" She cites a dream she had recently where she placed her hand at the entrance to the underworld which both scared her and caused her to realize she would miss her dog if she killed herself. She has multiple other protective factors, however, including strict medication adherence, attending frequent outpatient appointments, supportive friends and family, and future plans to be either a therapist or neuroscientist. Pt admits to frequent episodes of SH however it is usually restricted to cutting or scratching her arms until this presentation. She used broken glass she found outside to lacerate her throat "that way I could see more blood" referring to the vascularity of the neck. Decision was not impulsive, reports she found the glass in the middle of the night, cut at 3pm the next day, then finally told her dad later that night because she felt guilty. Denies particular stressor prompting increasing SH and admits she did not attempt to use her normal coping strategies (writing horror stories) because she "didn't feel like it." She cuts primarily to feel release ie when she gets "panicky" and "feels like [she] has to." Pt admits to significant guilt about the SH due to how it makes her dad feel and the increased concern she caused in her CAT Team. She denies any plans to harm herself here in the hospital and promises to alert someone if she feels the urge to harm herself.
Pt reports a good relationship with her father, however states that he will yell when she cuts herself and sometimes slam doors both of which make the situation worse. Pt also endorses previous physical abuse at the hand of her mother including 5 instances of slapping and pulling her hair, DCF was not involved, last incident 2 years ago and pt no longer lives with her mother. She does see her 2-3 times a week however and mother lives with two other siblings. DCF REPORT FILED. Pt endorses avoiding anything her mother likes, increased startle response, and nightmares regarding the abuse. She admits that she has not explored either of these stressors with her therapist.
Pt does report daily symptoms of anxiety that last all day, primarily regarding her advanced classes. She also endorses increasing symptoms of depression including anhedonia, difficulty initiating sleep, guilt, decreased energy. Overall, she feels that zoloft has helped her with her depression and anxiety, notes that her dose was recently increased. She denies AVH, no evidence of mania or delusions. Admits to remote but minimal alcohol use, see below. Denies using other substances.
Per parent:
Father reports cutting began last December with admissions beginning in March. He denies any particular trigger or stressor of which he is aware, however does say she has a girlfriend who also cuts and because pt cannot help her, she feels guilty and cuts more. He reports that pt also cuts her abdomen and legs and had one incident of self harm while in a mental health facility (cut herself with sharp object she found in the bathroom). Father confirms pt's previous suicide attempt via OD on 250 pills of benadryl requiring significant medical attention. He reports her CAT team wants her to go to another residential facility due to this most recent event; however, he does not prefer this and would like to do everything possible before sending her. He feels like residential and hospital admissions are "breaking her," that his daughter thinks people are giving up on her when they send her away. He however will approve of whatever is best for his daughter. He signed a release of previous history documented by her CAT team and gives number for the therapist.
He gives verbal consent for naltrexone in addition to meds for which he has already signed in person when pt was admitted.
(from chart and updated as appropriate)
Past Psychiatric History
Inpatient treatment: recently 35 days in residential, multiple admissions: Nicklaus twice, Larkin once, Citrus 3-4 times, for SI and SH
Outpatient treatment: sees both psychiatrist and therapist in Key West regularly
Suicide History: 2 previous attempts, one less than 3 months ago took 250 pills benadryl
Past psychiatric medications: Lexapro dc'd due to inadequate response, vistaril inadequate response
Current psychiatric medications: Abilify 10mg daily, Zoloft 150mg daily (recently increased)
Medical History
Past medical history: denies
Past surgical history: denies
Seizures: denies
Loss of consciousness: denies
Traumatic brain injury: denies
Current nonpsychiatric medications: denies
Allergies
NKA
Substance Use History
Tobacco: denies
Alcohol: previous use, minimal. last drink 3-4months ago admits to drinking 4-5 drinks in a single sitting though frequency was only ever once every few months
Cannabis: denies
Cocaine: denies
Opioids: denies
Benzodiazepines: denies
Amphetamines: denies
Hallucinogens: denies
Detox/Rehab: denies
Trauma History
Physical: mother slapped her and pulled her hair approx 5 times, last time 2 years ago, no longer lives with mother though sees her 2-3x per week
Sexual: denies
Neglect: denies
Family History
Mental illness: depression and anxiety in mother, grandfather, and brother
Suicide attempts: denies
Substance abuse: denies
Developmental History
Birth history: vaginal
Developmental milestones:
walked at: early
talked at: early
toilet trained: early
Social: wnl however father notes pt more of an introvert, rather would stay in.
Psychosocial History
Born: Virginia
Raised: frequent moving, Key West for last 5 years
Siblings: 2 brothers 1 sister
Lives with: father /Parent are divorce
Relationship: friend she calls girlfriend, father unsure if romantic
Educational History
Grade: 9th, pt denies bullying
School: Key West High School
Grades: excellent, Father reports pt could recite the whole periodic table in 5th grade.
Suspensions: denies
Legal History
Legal guardian: father and mother joint custody
History of arrest: denies
Review of Systems
General: does not endorse fevers or weight change
HEENT: does not endorse sore throat or congestion
Cardiovascular: does not endorse chest pain or palpitations
Respiratory: does not endorse cough or wheezing
Gastrointestinal: does not endorse nausea, vomiting, or changes in bowel habits
Genitourinary: does not endorse dysuria or change in bladder habits
Neurological: does not endorse dizziness or numbness
MSK: does not endorse muscle or joint pain
Vital Signs
Temperature 36.9 (06:57)
Systolic Blood Pressure 113 (06:57)
Diastolic Blood Pressure 77 (06:57)
Pulse 75 (06:57)
SpO2 100 (06:57)
Respiratory Rate 18 (06:57)
Mental Status Exam
Appearance: well-groomed with good hygiene, significant number of superficial lacerations and scratches on bilateral arms of varying stages of healing, and across anterior neck
Behavior: calm and cooperative with interview
Orientation: awake, alert, oriented to person, location, date, situation
Speech: normal rate and rhythm, appropriate volume, spontaneous, comprehensible
Eye Contact: good
Motor Activity: no PMA/PMR/AIMs noted
Mood: "good"
Affect: reactive, full range
Thought Process: organized, goal directed
Thought Content: no delusions, preoccupations, obsessions, compulsions, or phobias elicited
Suicidal Ideation/Thought/Intent/Plan: denies
Homicidal Ideation/Thought/Intent/Plan: denies
Perceptual Disturbances: denies AVTOG hallucinations
Insight/Judgment: good/poor
Attention/Concentration: good/good
Memory: grossly intact
Scales
Differential
DSM-5 Diagnosis:
Depressive Disorder Unspecified F32.9
Anxiety Disorder Unspecified F41.9
Unspecified mood [affective] disorder (F39)
1. Occupational/Recreational/Activity Therapy: will participate
2. School: will attend
3. Scales: n/a
4. Information: previous records, school information
5. Studies to be ordered: n/a
6. Precautions: Line of sight
7. Individual sessions: psychoeducation, safety, coping skills
8. Family sessions: psychoeducation, safety, length of stay
9. Medications: continue Abilify 10mg QHS and zoloft 150mg daily. Start Naltrexone 25mg PO daily
Medication List
Active Medications
Ordered
acetaminophen: 325 mg, 1 tab, ORAL, Q6H, PRN: Pain – Mild.
ARIPiprazole: 10 mg, 1 tab, ORAL, BEDTIME.
diphenhydrAMINE: 50 mg, 1 cap, ORAL, BEDTIME, PRN: Insomnia.
hydrOXYzine: 50 mg, 1 cap, ORAL, Q6H, PRN: Anxiety.
melatonin: 5 mg, 1 tab, ORAL, BEDTIME, PRN: as needed for insomnia.
naltrexone: 25 mg, 0.5 tab, ORAL, DAILY.
sertraline: 150 mg, 3 tab, ORAL, DAILY.
Documented
ARIPiprazole: 106.
sertraline: 106.
Medications Inactivated in the Last 72 Hours
No medications found.
10. Aftercare planning: medication management, family therapy, continue with services provided by CAT team
11. Estimated length of stay: tbd, likely Fri or Sat
· State 3–4 objectives for the presentation that are targeted, clear, use appropriate verbs from Bloom’s taxonomy, and address what the audience will know or be able to do after viewing.
· Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
· Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
· Pose three questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.
· Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide.
· 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 their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5 -TR diagnostic criteria and is supported by the patient’s symptoms.
· Plan: What was your plan for psychotherapy (include one health promotion activity and patient education)? What was 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. Discuss an identified social determinate of health impacting this patient’s mental health status and provide your recommendation for a referral to assist this patient in meeting this identified need (students will need to conduct research on this topic both in the literature and for community resources).
· Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow-up, discuss what your next intervention would be.
Make sure all these are covers below:
· 3–4 objectives provided and written in terms of what the audience will know or be able to do after viewing. Appropriate Bloom's verbs are used. Objectives are targeted and clear.
· Accurately and concisely presents the patient's subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis.
· accurately and concisely documents the patient's physical exam for pertinent systems. Pertinent diagnostic tests and their results are documented, as applicable.
· accurately documents the results of the mental status exam. presents at least 3 differentials in order of priority for a differential diagnosis of the patient, and a rationale for their selection…. Response justifies the primary diagnosis and how it aligns with DSM-5-TR criteria.
· clearly and concisely outlines an evidence-based treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear and concise rationale for the treatment approaches recommended is provided. Discussion includes a social determinate of health need impacting mental health status with referral recommendation and evidence of researching literature and incorporating local community resources
· Reflections are thorough, thoughtful, and demonstrate critical thinking…. Questions or prompts for colleagues are thought-provoking and will require substantive responses and critical thinking.
· include objectives for your audience, and at least 3 possible discussion questions/prompts for your classmates to respond to, and at least 5 scholarly resources to support your diagnostic reasoning and treatment plan.
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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 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 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
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.
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.).
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