What observations did you make during the psychiatric assessment?

Assignment 2: Focused SOAP Note and Patient Case
Presentation
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
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.

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

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 diagnostic criteria and supported by
the patient’s symptoms.
Plan: What
was your plan for psychotherapy? 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. Also be sure to include at least 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? 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.

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