U3 : | Nursing

Clinical Requirement:

U-SOAP.SEEattached.docx Unit 3-Clinical SOAP Note. On Majoy depressive disorder. This week topic is MDD. Please follow attached template and rubric below. Due 1-24-25. Instructions Each week students will choose one patient encounter to submit a Follow-up SOAP note for review.  Follow the rubric to develop your SOAP notes for this term.  The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.  Note:  Grades of Incomplete on this assignment will result in a clinical failure. All work should be original and submitted as a Word document unless otherwise indicated in the assignment instructions. ALL assignments need to be APA 7 format and accompanied title page in APA 7th edition format in order that the work would be properly identified for the student, the course, and the assignment. Work submitted without a title page will receive a grade of 0. Upload note to TurnItIn plagiarism checker for grade submission. Program Outcomes 1. Demonstrate critical thinking and holistic caring as an advanced practice 2. Analyze scientific literature for application to selected diagnoses and treatment plans. 3. Synthesize ethical principles into the management and evaluation of healthcare delivery concerns in culturally diverse care settings. 4. Articulate a personal philosophy and framework acknowledging professional and accrediting agency competencies relating to the role and scope of practice of the psychiatric mental health nurse practitioner. 5. Implement the role of the psychiatric mental health nurse practitioner in selected clinical settings. Course Learning Objectives By the end of this course, you will be able to: 1. Independently with mentor supervision, apply knowledge of chronic and acute psychiatric mental health disorders using the current edition of the Diagnostic and Statistical Manual for Mental Disorders diagnostic criteria to assess, diagnose and manage the patient populations across the lifespan including a focus on vulnerable populations at risk for mental health disorders. 2. Independently with mentor supervision, integrate complete mental health assessment, interview, history, and physical exam data collection with the knowledge of pathophysiology and psychopathology of psychiatric mental health disorders across the life span to form differential diagnoses and implement therapeutic, patient-centered treatment plans and interventions for patient populations across the lifespan. 3. Independently with mentor supervision, merge traditional and complementary pharmacological/non-pharmaceutical interventions into the treatment and management of psychiatric mental health disorders for patient populations across the lifespan. 4. Independently with mentor supervision, examine, evaluate, and demonstrate professional development in the role of the nurse practitioner in the diagnosis and management of health and wellness as well as acute and chronic psychiatric mental health disorders illnesses for patient populations across the lifespan as a member of an interprofessional team. 5. Independently with mentor supervision, integrate cultural, spiritual, and social competencies into therapeutic patient-centered treatment plans in connection with evidence-based findings to the diagnosis and management of individuals, groups, and families across the lifespan with acute, complex, and chronic psychiatric mental health disorders. 6. Independently with mentor supervision, analyze professional values and core ethical/legal standards into the practice of the Psychiatric Mental Health Nurse Practitioner role with relation to patient/staff safety, quality indicators, and health outcome improvement in the delivery of quality psychiatric mental health care to patients. 7. Identifies with mentor supervision, the highest level of professionalism and accountability for the PMHNP role for transition into clinical practice. Resources American Nurses Association & American Psychiatric Nurse Association. (2015).  Psychiatric–mental health nursing: Scope and standards of practice (2nd ed.) American Nurses Credentialing. ISBN-13: 978-1558105553 ISBN-10: 1558105557   American Psychiatric Association. (2022).  Diagnostic and statistical manual of mental disorders (5th ed.) text revision (DSM-5 TR). APA Press. ISBN 978-0890425763 Carlat, D. J. (2023).  The psychiatric interview (5th ed.). Philadelphia, PA: Wolters Kluwer. ISBN: 9781975212971 Boland, R., Verduin, M., & Ruiz, P. (2022 ) Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer. ISBN: 9781975145569 Stahl, S. M. (2022).  Stahl's essential psychopharmacology: Neuroscientific basis and practical applications (5th ed.). Cambridge University Press. ISBN 978-1-108-97163-8 Bickley, L. (2016).  Bates' Guide to Physical Examination and History-Taking (11th ed) [VitalSouce bookshelf version]. https://batesvisualguide.com/. Lippincott Williams & Wilkins: ISBN 1609137620   Corey, G. (2016).  Theory and practice of counseling and psychotherapy (10th ed.). Cengage. ISBN: 9781305263727   Heldt, J. P., MD. (2017).  Memorable psychopharmacology. Create Space Independent Publishing Platform. ISBN-13: 978-1-535-28034-1   Johnson, K., & Vanderhoef, D. (2016).  Psychiatric mental health nurse practitioner review manual (4th ed.). American Nurses Association. ISBN: 978-1-935213-79-6   Stahl, S. M. (2020).  Prescriber's guide: Stahl's essential psychopharmacology (7th ed.). Cambridge University Press. ISBN 978-1108926010   · Learner Resources  Download Learner Resources [PDF] · Printable Full Syllabus  Download Printable Full Syllabus [PDF] image1.png image2.png image3.png HUInitialMHASOAPNoteTemplate1222.docx Initial Psychiatric Interview/SOAP Note Template There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to develop your style of SOAP in the psychiatric practice setting. Criteria Clinical Notes Informed Consent Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion) Subjective Verify Patient Name: DOB: Minor: Accompanied by: Demographic: Gender Identifier Note: CC: HPI: Pertinent history in record and from patient: X During assessment: Patient describes their mood as X and indicated it has gotten worse in TIME. Patient self-esteem appears fair, no reported feelings of excessive guilt, no reported anhedonia, does not report sleep disturbance, does not report change in appetite, does not report libido disturbances, does not report change in energy, no reported changes in concentration or memory. Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. Patient does not report excessive fears, worries or panic attacks. Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a characterological nature. SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors. Allergies: NKDFA. (medication & food) Past Medical Hx: Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury. Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C. Surgical history no surgical history reported Past Psychiatric Hx: Previous psychiatric diagnoses: none reported. Describes stable course of illness. Previous medication trials: none reported. Safety concerns: History of Violence to Self: none reported History of Violence t o Others: none reported Auditory Hallucinations: Visual Hallucinations: Mental health treatment history discussed: History of outpatient treatment: not reported Previous psychiatric hospitalizations: not reported Prior substance abuse treatment: not reported Trauma history: Client does not report history of trauma including abuse, domestic violence, witnessing disturbing events. Substance Use: Client denies use or dependence on nicotine/tobacco products. Client does not report abuse of or dependence on ETOH, and other illicit drugs. Current Medications: No current medications. (Contraceptives): Supplements: Past Psych Med Trials: Family Medical Hx: Family Psychiatric Hx: Substance use Suicides Psychiatric diagnoses/hospitalization Developmental diagnoses Social History: Occupational History: currently unemployed. Denies previous occupational hx Military service History: Denies previous military hx. Education history: completed HS and vocational certificate Developmental History: no significant details reported. (Childhood History include in utero if available) Legal History: no reported/known legal issues, no reported/known conservator or guardian. Spiritual/Cultural Considerations: none reported. ROS: Constitutional: No report of fever or weight loss. Eyes: No report of acute vision changes or eye pain. ENT: No report of hearing changes or difficulty swallowing. Cardiac: No report of chest pain, edema or orthopnea. Respiratory: Denies dyspnea, cough or wheeze. GI: No report of abdominal pain. GU: No report of dysuria or hematuria. Musculoskeletal: No report of joint pain or swelling. Skin: No report of rash, lesion, abrasions. Neurologic: No report of seizures, blackout, numbness or focal weakness. Endocrine: No report of polyuria or polydipsia. Hematologic: No report of blood clots or easy bleeding. Allergy: No report of hives or allergic reaction. Reproductive: No report of significant issues. (females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…) Verify Patient: Name, Assigned  identification number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo. Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview. HPI: , Past Medical and Psychiatric History, Current Medications, Previous Psych Med trials, Allergies. Social History, Family History. Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…” Objective Vital Signs: Stable Temp: BP: HR: R: O2: Pain: Ht: Wt: BMI: BMI Range: LABS: Lab findings WNL Tox screen: Negative Alcohol: Negative HCG: N/A Physical Exam: MSE: Patient is cooperative and conversant, appears without acute distress, and fully oriented x 4. Patient is dressed appropriately for age and season. Psychomotor activity appears within normal. Presents with appropriate eye contact, euthymic affect - full, even, congruent with reported mood of “x”. Speech: spontaneous, normal rate, appropriate volume/tone with no problems expressing self. TC: no abnormal content elicited, denies suicidal ideation and denies homicidal ideation. Process appears linear, coherent, goal-directed. Cognition appears grossly intact with appropriate attention span & concentration and average fund of knowledge. Judgment appears fair . Insight appears fair The patient is able to articulate needs, is motivated for compliance and adherence to medication regimen. Patient is willing and able to participate with treatment, disposition, and discharge planning. This is where the “facts” are located. Vitals, **Physical Exam (if performed, will not be performed every visit in every setting) Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results. Assessment DSM5 Diagnosis: with ICD-10 codes Dx: - Dx: - Dx: - Patient has the ability/capacity appears to respond to psychiatric medications/psychotherapy and appears to understand the need for medications/psychotherapy and is willing to maintain adherent. Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment. Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment. Informed Consent Ability Plan (Note some items may only be applicable in the inpatient environment) Inpatient: Psychiatric. Admits to X as per HPI. Estimated stay 3-5 days Safety Risk/Plan: Patient is found to be stable and has control of behavior. Patient likely poses a minimal risk to self and a minimal risk to others at this time. Patient denies abnormal perceptions and does not appear to be responding to internal stimuli. Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic: · No changes to current medication, as listed in chart, at this time · or…Zoloft is an excellent option for many women who experience any menstrual cycle complaints. I usually start at 50 mg and move to 100 week 6-8. f/u within 2 weeks initially then every 6-8 weeks. · Psychotherapy referral for CBT Education, including health promotion, maintenance, and psychosocial needs · Importance of medication · Discussed current tobacco use. NRT not indicated. · Safety planning · Discuss worsening sx and when to contact office or report to ED Referrals: endocrinologist for diabetes Follow-up, including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit 2 weeks ☒ > 50% time spent counseling/coordination of care. Time spent in Psychotherapy 18 minutes Visit lasted 55 minutes Billing Codes for visit: XX XX XX ____________________________________________ NAME, TITLE Date: Click here to enter a date. Time: X