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

• 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:
  • All SOAP notes must be signed, and each page must be initialed by your Preceptor. Note: Electronic signatures are not accepted.
  • 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.
  • 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 study for your clinical patient. In your presentation:

• Dress professionally with a lab coat 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:
  • 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.

Prepare a 10-15 slide PowerPoint presentation, with speaker notes, that examines the significance of an organization’s culture and values. For the presentation of your PowerPoint, use Loom to create a voice-over or a video. Refer to the Topic Materials for additional guidance on recording your presentation with Loom. Include an additional slide for the Loom link at the beginning, and an additional slide for References at the end.

1. Outline the purpose of an organization’s mission, vision, and values.
2. Explain why an organization’s mission, vision, and values are significant to nurse engagement and patient outcomes.
3. Explain what factors lead to conflict in a professional practice. Describe how organizational values and culture can influence the way conflict is addressed.
4. Discuss effective strategies for resolving workplace conflict and encouraging interprofessional collaboration.
5. Discuss how organizational needs and the culture of health care influence organizational outcomes. Describe how these relate to health promotion and disease prevention from a community health perspective.

While APA style format is not required for the body of this assignment, solid academic writing is expected, and in-text citations and references should be presented using APA documentation guidelines.

Discussion: Comprehensive Integrated Psychiatric Assessment

Photo Credit: Seventyfour / Adobe Stock

Many assessment principles are the same for children and adults; however, unlike with adults/older adults, where consent for participation in the assessment comes from the actual client, with children it is the parents or guardians who must make the decision for treatment. Issues of confidentiality, privacy, and consent must be addressed. When working with children, it is not only important to be able to connect with the pediatric patient, but also to be able to collaborate effectively with the caregivers, other family members, teachers, and school counselors/psychologists, all of whom will be able to provide important context and details to aid in your assessment and treatment plans.

Some children/adolescents may be more difficult to assess than adults, as they can be less psychologically minded. That is, they have less insights into themselves and their motivations than adults (although this is not universally true). The PMHNP must also take into consideration the child’s culture and environmental context. Additionally, with children/adolescents, there are lower rates of neurocognitive disorders superimposed on other clinical conditions, such as depression or anxiety, which create additional diagnostic challenges. 

In this Discussion, you review and critique the techniques and methods of a mental health professional as the practitioner completes a comprehensive, integrated psychiatric assessment of an adolescent. You also identify rating scales and treatment options that are specifically appropriate for children/adolescents. 

To Prepare

• Review the Learning Resources and consider the insights they provide on comprehensive, integrated psychiatric assessment. Watch the Mental Status Examination B-6 and Simulation Scenario-Adolescent Risk Assessment videos.
• Watch the YMH Boston Vignette 5 video and take notes; you will use this video as the basis for your Discussion post.

By Day 3 of Week 1

Based on the YMH Boston Vignette 5 video, post answers to the following questions:

• What did the practitioner do well? In what areas can the practitioner improve?
• At this point in the clinical interview, do you have any compelling concerns? If so, what are they?
• What would be your next question, and why?

Then, address the following. Your answers to these prompts do not have to be tailored to the patient in the YMH Boston video.

• Explain why a thorough psychiatric assessment of a child/adolescent is important.
• Describe two different symptom rating scales that would be appropriate to use during the psychiatric assessment of a child/adolescent.
• Describe two psychiatric treatment options for children and adolescents that may not be used when treating adults.
• Explain the role parents/guardians play in assessment.

Support your response with at least three peer-reviewed, evidence-based sources and explain why each of your supporting sources is considered scholarly. Attach the PDFs of your sources.

Choose one specific cultural group in the U.S. or elsewhere for which you have a particular interest.  You may wish to consider choosing a cultural group that you will be serving in your future advanced nursing role. Conduct a literature search for varied types of credible, peer-reviewed scholarly publications which may include journal articles, book chapters, white papers; government publications or sources such as credible professional nursing and healthcare organizations. Prepare a voice-narrated powerpoint slide presentation which concisely addresses key points in items one through five below as they apply to your chosen cultural group. Include a title slide which names the chosen culture, your name and academic credentials and a reference slide with only selected key citations cited in the slide presentation.

Required Content for Powerpoint Presentation

1. What are the appropriate interdisciplinary interventions for hereditary, genetic, and endemic diseases and high-risk health behaviors within this culture?
2. What are the influences of value systems in this culture on childbearing and bereavement practices?
3. What are the sources of strength, spirituality, and magico- religious beliefs associated with health and health care within this culture?
4. What are the healthcare practices for this culture such as  acute versus preventive care, barriers to healthcare, the meaning of pain and the sick role; and traditional folk medicine practices?
5. What are cultural issues related to learning styles, autonomy, and preparation of educational content for this culture?