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Focused SOAP Note and Patient Case Presentation

Assignment 2: Focused SOAP Note and Patient Case Presentation 

 

Photo Credit: Pexels

Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will document information about a patient that you examined during the last three weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient. 

To Prepare

Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.

Select a patient of any age (either a child or an adult) that you examined during the last 3 weeks.

Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations. 

Please Note:

o All SOAP notes must be signed, and each page must be initialed by your Preceptor. Note: Electronic signatures are not accepted.

o When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor.

o You must submit your SOAP note using SafeAssign. Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.

Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record. 

Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.

Ensure that you have the appropriate lighting and equipment to record the presentation.

The Assignment

Record yourself presenting the complex case for your clinical patient.

Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video. 

In your presentation:

Dress professionally and present yourself in a professional manner.

Display your photo ID at the start of the video when you introduce yourself.

Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).

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.

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:

o 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?

o Objective: What observations did you make during the psychiatric assessment? 

o 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 diagnostic criteria and supported by the patient’s symptoms.

o Plan: In your video, describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session? 

o In your written plan include all the above as well as include one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.

o 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.

 

 

 

Name: PRAC_6665_Week3_Assignment2_Rubric

Grid View

List View

  Excellent Good Fair Poor

Photo ID display and professional attire 5 (5%) – 5 (5%)

Photo ID is displayed. The student is dressed professionally. 0 (0%) – 0 (0%) 0 (0%) – 0 (0%) 0 (0%) – 0 (0%)

Photo ID is not displayed. Student must remedy this before grade is posted. The student is not dressed professionally.

Time 5 (5%) – 5 (5%)

The video does not exceed the 8-minute time limit. 0 (0%) – 0 (0%) 0 (0%) – 0 (0%) 0 (0%) – 0 (0%)

The video exceeds the 8-minute time limit. (Note: Information presented after 8 minutes will not be evaluated for grade inclusion.)

Discuss Subjective data:

 

• Chief complaint

 

• History of present illness (HPI)

 

• Medications

 

• Psychotherapy or previous 

psychiatric diagnosis

 

• Pertinent histories and/or ROS 9 (9%) – 10 (10%)

The video 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. 8 (8%) – 8 (8%)

The video accurately 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. 7 (7%) – 7 (7%)

The video 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, but is somewhat vague or contains minor inaccuracies. 0 (0%) – 6 (6%)

The video presents an incomplete, inaccurate, or unnecessarily detailed/verbose description of 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. Or subjective documentation is missing.

Discuss Objective data:

 

• 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 9 (9%) – 10 (10%)

The video accurately and concisely documents the patient’s physical exam for pertinent systems. Pertinent diagnostic tests and their results are documented, as applicable. 8 (8%) – 8 (8%)

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are documented, as applicable. 7 (7%) – 7 (7%)

Documentation of the patient’s physical exam is somewhat vague or contains minor inaccuracies. Diagnostic tests and their results are documented but contain inaccuracies. 0 (0%) – 6 (6%)

The response provides incomplete, inaccurate, or unnecessarily detailed/verbose documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or objective documentation is missing.

Discuss results of Assessment:

 

• Results of the mental status examination

 

• Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms. 18 (18%) – 20 (20%)

The video accurately documents the results of the mental status exam. 

 

Video presents at least three 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 criteria. 16 (16%) – 17 (17%)

The video adequately documents the results of the mental status exam. 

 

Video presents three differentials for the patient and a rationale for their selection. Response adequately justifies the primary diagnosis and how it aligns with DSM-5 criteria. 14 (14%) – 15 (15%)

The video presents the results of the mental status exam, with some vagueness or inaccuracy. 

 

Video presents three differentials for the patient and a rationale for their selection. Response somewhat vaguely justifies the primary diagnosis and how it aligns with DSM-5 criteria. 0 (0%) – 13 (13%)

The response provides an incomplete, inaccurate, or unnecessarily detailed/verbose description of the results of the mental status exam and explanation of the differential diagnoses. Or assessment documentation is missing.

Discuss treatment Plan:

 

• A treatment plan for the patient that addresses chosen FDA-approved psychopharmacologic agents and includes alternative treatments available and supported by valid research. The treatment plan includes rationales, a plan for follow-up parameters, and referrals. The discussion includes one social determinant of health according to the HealthyPeople 2030, one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health. 18 (18%) – 20 (20%)

The video clearly and concisely outlines an evidence-based treatment plan for the patient that addresses FDA-approved psychopharmacologic agents and includes alternative treatments and rationale supported by valid research. 

 

Discussion includes a clear and concise follow-up plan and parameters.

 

The discussion includes a clear and concise referral plan. 

 

The paper discussion contains all 3 elements from the assignment directions including a discussion demonstrating critical thinking of the case related to the HealthyPeople 2030 social health determinates. Clearly and concisely relates discussion to the psychiatric and mental health field. 16 (16%) – 17 (17%)

The video clearly outlines an appropriate treatment plan without evidence-based discussion for the patient that addresses FDA-approved psychopharmacologic agents and includes alternative treatments and rationale supported by vague or questionable research. 

 

Discussion includes a clear follow-up plan and parameters.

 

The discussion includes a clear referral plan.

 

The paper discussion contains 2 of the elements from the assignment directions with one being a basic discussion of the case related to the HealthyPeople 2030 social health determinates. Clearly relates discussion to the psychiatric and mental health field. 14 (14%) – 15 (15%)

The response somewhat vaguely or inaccurately outlines a treatment plan for the patient that addresses psychopharmacologic agents without discussion of FDA approval and includes vague or inaccurate alternative treatments with little rationale discussed. 

 

The discussion is somewhat vague or inaccurate regarding the follow-up plan and parameters.

 

The discussion is somewhat vague or inaccurate regarding a referral plan. 

 

The paper discussion contains 1 of the required elements from the assignment directions which is the HealthyPeople 2030 social health determinates.

 

Somewhat vaguely or inaccurately relates discussion to the psychiatric and mental health field. 0 (0%) – 13 (13%)

The response does not address the treatment plan or the treatment plan is not appropriate for the assessment and the diagnosis. There is no mention of FDA approval for treatment choices or no research supported discussion. Alternative treatment discussion is missing. 

 

Rationales for treatments are missing. 

 

There is no discussion for follow-up and parameters. 

 

There is no discussion of a referral plan. 

 

The paper discussion is missing discussion relating to the psychiatric and mental health field or relates discussion to another specialty realm including medical co-morbidity illnesses.

Reflect on this case. Discuss what you learned and what you might do differently. 5 (5%) – 5 (5%)

Reflections are thorough, thoughtful, and demonstrate critical thinking. 4 (4%) – 4 (4%)

Reflections demonstrate critical thinking. 3.5 (3.5%) – 3.5 (3.5%)

Reflections are somewhat general or do not demonstrate critical thinking. 0 (0%) – 3 (3%)

Reflections are incomplete, inaccurate, or missing.

Focused SOAP Note documentation 18 (18%) – 20 (20%)

The response clearly, accurately, and thoroughly follows the Focused SOAP Note format to document the selected patient case. 16 (16%) – 17 (17%)

The response accurately follows the Focused SOAP Note format to document the selected patient case. 14 (14%) – 15 (15%)

The response follows the Focused SOAP Note format to document the selected patient case, with some vagueness and inaccuracy. 0 (0%) – 13 (13%)

The response incompletely and inaccurately follows the Focused SOAP Note format to document the selected patient case.

Presentation style 5 (5%) – 5 (5%)

Presentation style is exceptionally clear, professional, and focused. 4 (4%) – 4 (4%)

Presentation style is clear, professional, and focused. 3.5 (3.5%) – 3.5 (3.5%)

Presentation style is mostly clear, professional, and focused 0 (0%) – 3 (3%)

Presentation style is unclear, unprofessional, and/or unfocused.

Total Points: 100

Name: PRAC_6665_Week3_Assignment2_Rubric

 

                                                   CASE PRESENTATION 

 

R.S. is a 34-year-old AA male with previous psychiatric history of schizoaffective 

disorder, bipolar type, depression and anxiety, impulse control disorder, and substance 

use, who presents to the clinic for medication refill. R.S. States he is here to get a refill for

his medication because it was lost at the half-way house. He complains of difficulty falling 

asleep and staying asleep. He says he sleeps 3 hours a night. He denies SI/HI or 

psychosis at present. He states he just needs a refill sent for his Zyprexa. He admits to 

occasional use of tobacco, marijuana, heroin, cocaine, and ETOH. The patient has a 

high school diploma, lives in a half-way house and he is a mechanic by trade. He is 

currently on parole or probation for possession of a control substance. He has never been

married, has no children but has a girlfriend for 5 years. He has one incident of DUI when 

he was 31 years old. He seems to be minimizing the amount of illicit drugs and alcohol 

that he takes.

 

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