PRAC 6665 Focused SOAP Note and Patient Case Presentation Assignment

PRAC 6665 Focused SOAP Note and Patient Case Presentation Assignment

PRAC 6665 Week 7 Assignment 2

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 it.
  • 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.

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The Assignment

Record yourself presenting the complex case study for your clinical patient. In your presentation:

  • Dress professionally in 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).

PRAC 6665 Focused SOAP Note and Patient Case Presentation Essay

  • 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 is 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. PRAC 6665 Week 6 Assignment 

By Day 7 of Week 3

Submit your Video and Focused SOAP Note Assignment. You must submit two files for the note, including a Word document and scanned pdf/images of each page that is initialed and signed by your Preceptor.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

  • Please save your Assignment using the naming convention “WK3Assgn2+last name+first initial. (extension)” as the name.
  • Click the Week 3 Assignment 2 Rubric to review the Grading Criteria for the Assignment.
  • Click the Week 3 Assignment 2 link. You will also be able to “View Rubric” for grading criteria from this area.
  • Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK3Assgn2+last name+first initial. (extension)” and click Open.
  • If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
  • Click on the Submit button to complete your submission.

Introduction

  • When setting sharp, clearly defined goals and objectives, you focus on what you wish to accomplish and how and when you will get there. Based on your assessment of your strengths and opportunities related to psychiatric-mental health nurse practitioner (PMHNP) clinical skills, you can develop goals and objectives for your clinical practicum that can guide your activities. What are some steps you can take on the way to a larger goal? How might you gain confidence in a clinical skill or seek out more opportunities to practice? What external activities might boost your professionalism or enhance your skill set? As you settle in at your practicum site, keep these questions in mind.
  • This week, you continue engaging with patients at your practicum site, recording your time and experiences in your Clinical Hour and Patient Logs. You will also develop a Practicum Experience Plan (PEP) made up of goals and objectives designed to formally identify specific categories of clinical skills you wish to gain during your practicum experience.

Learning Objectives

Students will:
• Describe clinical hours and patient encounters
• Develop a Practicum Experience Plan
• Create a timeline of practicum activities based on your practicum requirements
________________________________________
Learning Resources

Required Readings (click to expand/reduce)

American Academy of Child and Adolescent Psychiatry. (n.d.). Toolbox of forms. Retrieved November 18, 2020, from
https://www.aacap.org/AACAP/Member_Resources/AACAP_Toolbox_for_Clinical_Practice_and_Outcomes/Forms.aspx

American Geriatrics Society 2019 Beers Criteria Update Expert Panel. (2019). American Geriatrics Society 2019 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 67(4), 674–694. https://doi.org/10.1111/jgs.15767

Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
• Section I. General Principles of Effective Interviewing (Chapters 1–13)
• Section III. Interviewing for Diagnosis: The Psychiatric Review of Symptoms (Chapters 19–22)
• Appendixes A–C

MediaTek
https://edu.meditrek.com/Default.html
Note: Use this link to log into Meditrek to report your clinical hours and patient encounters.

Pumariega, A. J., Rothe, E., Mian, A., Carlisle, L., Toppelberg, C., Harris, T., Gogineni, R. R., Webb, S., Smith, J., & American Academy of Child and Adolescent Psychiatry Committee on Quality Issues. (2013). Practice parameter for cultural competence in child and adolescent psychiatric practice. Journal of the American Academy of Child and Adolescent Psychiatry, 52(10), 1101–1115. https://doi.org/10.1016/j.jaac.2013.06.019

Walden University Academic Skills Center. (2017). Developing SMART goals.
https://academicguides.waldenu.edu/ld.php?content_id=51901492

Document: Practicum Experience Plan Template (Word document)

________________________________________
Reminder: Introductory Communication

Photo Credit: Ellagrin / iStock / Getty Images Plus / Getty Images
This week, you must coordinate an introductory email with your Clinical Faculty and Preceptor. The purpose of this communication is for orientation and onboarding, goals discussion, and questions. PRAC 6665 Focused SOAP Note and Patient Case Presentation Assignment 
By Day 7 of Week 2
Complete your orientation email. Attach your clinical schedule calendar developed in Week 1 in your email. Include a summary of your goals and objectives for this practicum experience.

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