Develop a focused SOAP note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:
Submit your Focused SOAP Note.
[MUSIC PLAYING] DR. MOORE: Good afternoon. I’m Dr. Moore. Want to thank you for coming
in for your appointment today. I’m going to be asking you some
questions about your history and some symptoms. And to get started,
I just want to ensure I have the right
patient and chart. So can you tell me your
name and your date of birth? SHERMAN TREMAINE:
I’m Sherman Tremaine, and Tremaine is my game game. My birthday is November 3, 1968. DR. MOORE: Great. And can you tell
me today’s date? Like the day of the week,
and where we are today? SHERMAN TREMAINE: Use any recent
date, and any location is OK. DR. MOORE: OK, Sherman. What about do you know
what month this is? SHERMAN TREMAINE: It’s March 18. DR. MOORE: And the
day of the week? SHERMAN TREMAINE: Oh, it’s a
Wednesday or maybe a Thursday. DR. MOORE: OK. And where are we today? SHERMAN TREMAINE:
I believe we’re in your office, Dr. Moore. DR. MOORE: OK, great. So tell me a little bit about
what brings you in today. What brings you here? SHERMAN TREMAINE: Well,
my sister made me come in. I was living with my
mom, and she died. I was living, and not bothering
anyone, and those people– those people, they just
won’t leave me alone. DR. MOORE: What people? SHERMAN TREMAINE: The ones
outside my window watching. They watch me. I can hear them, and
I see their shadows. They think I don’t
see them, but I do. The government sent
them to watch me, so my taxes are high,
so high in the sky. Do you see that bird? DR. MOORE: Sherman,
how long have you saw or heard these people? SHERMAN TREMAINE: Oh, for weeks,
weeks and weeks and weeks. Hear that– hear that
heavy metal music? They want you to think
it’s weak, but it’s heavy. DR. MOORE: No, Sherman. I don’t see any birds
or hear any music. Do you sleep well, Sherman? SHERMAN TREMAINE: I try to
but the voices are loud. They keep me up
for days and days. I try to watch TV, but they
watch me through the screen, and they come in
and poison my food. I tricked them though. I tricked them. I locked everything
up in the fridge. They aren’t getting in there. Can I smoke? DR. MOORE: No, Sherman. There is no smoking here. How much do you usually smoke? SHERMAN TREMAINE: Well,
I smoke all day, all day. Three packs a day. DR. MOORE: Three packs a day. OK. What about alcohol? When was your last drink? SHERMAN TREMAINE: Oh, yesterday. My sister buys me a 12-pack,
and tells me to make it last until next week’s grocery run. I don’t go to the grocery store. They play too loud of
the heavy metal music. They also follow me there. DR. MOORE: What about marijuana? SHERMAN TREMAINE: Yes,
but not since my mom died three years ago. DR. MOORE: Use any cocaine? SHERMAN TREMAINE: No,
no, no, no, no, no, no. No drugs ever, clever, ever. DR. MOORE: What about
any blackouts or seizures or see or hear things
from drugs or alcohol? SHERMAN TREMAINE: No, no, never
a clever [INAUDIBLE] ever. DR. MOORE: What about
any DUIs or legal issues from drugs or alcohol? SHERMAN TREMAINE:
Never clever’s ever. DR. MOORE: OK. What about any medication
for your mental health? Have you tried those before, and
what was your reaction to them? SHERMAN TREMAINE: I hate
Haldol and Thorazine. No, no, I’m not
going to take it. Risperidone gave me boobs. No, I’m not going to take it. Seroquel, that is OK. But they’re all poison,
nope, not going to take it. DR. MOORE: OK. So tell me, any
blood relatives have any mental health or
substance abuse issues? SHERMAN TREMAINE:
They say that my dad was crazy with
paranoid schizophrenia. He did in the old
state hospital. They gave him his beer there. Can you believe that? Not like them today. My mom had anxiety. DR. MOORE: Did any blood
relatives commit suicide? SHERMAN TREMAINE:
Oh, no demons there. No, no. DR. MOORE: What about you? Have you ever done anything
like cut yourself, or had any thoughts about killing
yourself or anyone else? SHERMAN TREMAINE:
I already told you. No demons there. Have been in the hospital three
times though when I was 20. DR. MOORE: OK. What about any medical issues? Do you have any
medical problems? SHERMAN TREMAINE: Ooh, I
take metformin for diabetes. Had or I have a fatty
liver, they say, but they never saw it. So I don’t know unless
the aliens told them. DR. MOORE: OK. So who raised you? SHERMAN TREMAINE: My
mom and my sister. DR. MOORE: And who
do you live with now? SHERMAN TREMAINE:
Myself, but my sister’s plotting with the
government to change that. They tapped my phone. DR. MOORE: OK. Have you ever been married? Are you single,
widowed, or divorced? SHERMAN TREMAINE: I’ve
never been married. DR. MOORE: Do you
have any children? SHERMAN TREMAINE: No. DR. MOORE: OK. What is your highest
level of education? SHERMAN TREMAINE: I
went to the 10th grade. DR. MOORE: And what do
you like to do for fun? SHERMAN TREMAINE: I don’t work,
so smoking and drinking pop. DR. MOORE: OK. Have you ever been arrested or
convicted for anything legally? SHERMAN TREMAINE: No, but
they have told me they would. They have told me they would
if I didn’t stop calling 911 about the people outside. DR. MOORE: OK. What about any kind of trauma
as a child or an adult? Like physical, sexual,
emotional abuse. SHERMAN TREMAINE: My dad was
rough on us until he died. DR. MOORE: OK. [MUSIC PLAYING] So thank you for answering
those questions for me. Now, let’s talk about
how I can best help you. [MUSIC PLAYING]
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.
Diagnostic Impression:
You must begin to narrow your differential diagnosis to your diagnostic impression. You must explain how and why (your rationale) you ruled out any of your differential diagnoses. You must explain how and why (your rationale) you concluded to your diagnostic impression. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.
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.).
Case Formulation and Treatment Plan
Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions including psychotherapy and/or psychopharmacology, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.
*See an example below. You will modify to your practice so there may be information excluded/included. If you are completing this for a practicum, what does your preceptor document?
Risks and benefits of medications are discussed including non- treatment. Potential side effects of medications discussed (be detailed in what side effects discussed). Informed client not to stop medication abruptly without discussing with providers. Instructed to call and report any adverse reactions. Discussed risk of medication with pregnancy/fetus, encouraged birth control, discussed if does become pregnant to inform provider as soon as possible. Discussed how some medications might decreased birth control pill, would need back up method (exclude for males).
Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. Discussed how drugs/alcohol affect mental health, physical health, sleep architecture.
Initiation of (list out any medication and why prescribed, any therapy services or referrals to specialist):
Client was encouraged to continue with case management and/or therapy services (if not provided by you)
Client has emergency numbers: Emergency Services 911, the Client’s Crisis Line
1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)
Reviewed hospital records/therapist records for collaborative information; Reviewed PMP report (only if actually completed)
Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (this relates to informed consent; you will need to assess their understanding and agreement)
Follow up with PCP as needed and/or for:
Labs ordered and/or reviewed (write out what diagnostic test ordered, rationale for ordering, and if discussed fasting/non fasting or other patient education)
Return to clinic:
Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care.
References (move to begin on next page)
You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
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