NURS6665 FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATIO Psychiatric notes are a

NURS6665
FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATIO
Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
Assignment
1- Introduction
2- For this Assignment, you will document information about a patient that you examined during the last 4 weeks, using the Focused SOAP Note Template provided. You will then use this note to develop a case presentation for this patient.
3- 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.
4- 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.
5- 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?
6- Objective: What observations did you make during the psychiatric assessment?
7- Assessment: Discuss patient mental status examination results
8- 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.
9- Plan:
a-describe your treatment plan using clinical practice guidelines supported by evidence-based practice.
b-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.
c-What were your follow-up plan and parameters?
d-What referrals would you make or recommend as a result of this treatment session?
e-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
f-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?
g-Demonstrate your critical thinking.
h-Reflection notes: What would you do differently with this patient if you could conduct the session over
i- If you are able to follow up with your patient, explain whether these interventions were successful and why or why not.
j- If you were not able to conduct a follow up, discuss what your next intervention would be.
FYI: Chosen case, SOAP template/exemplar are attached