Comprehensive Focused SOAP Psychiatric Evaluation|My essay solution

Posted: March 9th, 2023

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.

 

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

    NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

    Week (enter week #): (Enter assignment title)

    Student Name

    College of Nursing-PMHNP, Walden University

    PRAC 6665: PMHNP Care Across the Lifespan I

    Faculty Name

    Assignment Due Date

    Subjective:

    CC (chief complaint):

    HPI:

    Substance Current Use:

    Medical History:

    · Current Medications:

    · Allergies:

    · Reproductive Hx:

    ROS:

    · GENERAL:

    · HEENT:

    · SKIN:

    · CARDIOVASCULAR:

    · RESPIRATORY:

    · GASTROINTESTINAL:

    · GENITOURINARY:

    · NEUROLOGICAL:

    · MUSCULOSKELETAL:

    · HEMATOLOGIC:

    · LYMPHATICS:

    · ENDOCRINOLOGIC:

    Objective:

    Diagnostic results:

    Assessment:

    Mental Status Examination:

    Diagnostic Impression:

    Reflections:

    Case Formulation and Treatment Plan:

    PRECEPTOR VERFICIATION:

    I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

    Preceptor signature: ________________________________________________________

    Date: ________________________

    References

SOLUTION

Subjective:
John Doe is a 45-year-old male who presents with a chief complaint of anxiety and insomnia. He reports feeling constantly worried, restless, and unable to relax, which has been affecting his sleep for the past three weeks. He states that his anxiety is worst at night and that he has difficulty falling and staying asleep. John reports that he has always been a worrier, but it has gotten worse lately due to work-related stressors. He denies any past psychiatric diagnoses, including depression or bipolar disorder. He reports no suicidal ideation, homicidal ideation, or substance use.

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