Harassment and Retaliation in the Workplace HR T

Harassment and Retaliation in the Workplace
HR Training Presentation
z
z
What Every Employee
Needs to Know
Part 1: Harassment and Retaliation in the Workplace
z

Part 1 of your PowerPoint Presentation should consist of 5-10
slides.
2
Definitions & Examples
z
Describe harassment and retaliation in the workplace by
defining both terms and providing workplace examples of each.
3
FAQs: Questions & Answers
z
Provide at least 5 possible questions an employee might ask
about harassment and retaliation in the workplace and your
responses to those questions.
4
Recommended Resources
z

Identify at least 5 quality recommended resources you would
like every employee to have. Be sure to annotate each one with
a brief summary of the resource and your rationale for your
recommendation.
5
Making It Real!
z
Part 2 of your PowerPoint Presentation should consist of 6-10
slides.
6
Summarizing and Analyzing a Real Situation
z
Provide a summary of a situation from your work experience, or
reported abuse from a legitimate news report, demonstrating
harassment in the workplace, whether retaliation was involved,
and if so, in what ways.
7
Anticipating and Avoiding Retaliatory Actions
z

If you were the HR professional involved, what retaliatory
actions might you anticipate, and how might these be avoided?
8
What HR Professionals Need to Know
About the Law
z
Explain what you would need to know about the law in order to
handle the situation appropriately and effectively as an HR
professional.
9
Taking Steps for Prevention
z
Identify next steps that you would recommend to prevent this
situation from happening again.
10
Resources
z
List your resources for this PowerPoint Presentation on the next
slide.

11
RESOURCES
z
Your final slide should list in APA format the References that
support the content provided.
12
Rubric Detail
Select Grid View or List View to change the rubric's layout.
Content
Name: NRNP_6675_Week5_Assignment_Rubric
Grid ViewList View
Excellent
90%–100%
Good
80%–89%
Fair
70%–79%
Poor

0%–69%
Create documentation in the Focused SOAP Note Template
about your assigned patient.
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
Points:
Points Range:
14 (14%) - 15 (15%)

The response throughly and accurately describes the patient's
subjective complaint, history of present illness, past psychiatric
history, medication trials and current medications,
psychotherapy or previous psychiatric diagnosis, pertinent
histories, allergies, and review of all systems that would inform
a differential diagnosis.
Feedback:
Points:
Points Range:
12 (12%) - 13 (13%)

The response accurately describes the patient's subjective
complaint, history of present illness, past psychiatric history,
medication trials and current medications, psychotherapy or
previous psychiatric diagnosis, pertinent histories, allergies,
and review of all systems that would inform a differential
diagnosis.
Feedback:
Points:

Points Range:
11 (11%) - 11 (11%)
The response describes the patient's subjective complaint,
history of present illness, past psychiatric history, medication
trials and current medications, psychotherapy or previous
psychiatric diagnosis, pertinent histories, allergies, and review
of all systems that would inform a differential diagnosis but is
somewhat vague or contains minor innacuracies.
Feedback:
Points:

Points Range:
0 (0%) - 10 (10%)
The response provides an incomplete or inaccurate description
of the patient's subjective complaint, history of present illness,
past psychiatric history, medication trials and current
medications, psychotherapy or previous psychiatric diagnosis,
pertinent histories, allergies, and review of all systems that
would inform a differential diagnosis. Or the subjective
documentation is missing.
Feedback:
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
Points:
Points Range:
14 (14%) - 15 (15%)
The response thoroughly and accurately documents the
patient's physical exam for pertinent systems. Diagnostic tests
and their results are thoroughly and accurately documented.
Feedback:

Points:
Points Range:
12 (12%) - 13 (13%)
The response accurately documents the patient's physical exam
for pertinent systems. Diagnostic tests and their results are
accurately documented.
Feedback:

Points:
Points Range:
11 (11%) - 11 (11%)
Documentation of the patient's physical exam is somewhat
vague or contains minor innacuracies. Diagnostic tests and their
results are documented but contain minor innacuracies.
Feedback:

Points:
Points Range:
0 (0%) - 10 (10%)
The response provides incomplete or inaccurate documentation
of the patient's physical exam. Systems may have been
unnecessarily reviewed. Or the objective documentation is
missing.
Feedback:

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
diagnostic criteria for each differential diagnosis and explain
what DSM-5 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.
Points:
Points Range:
18 (18%) - 20 (20%)

The response thoroughly and accurately documents the results
of the mental status exam.
Response lists at least three distinctly different and detailed
possible disorders in order of priority for a differential
diagnosis of the patient in the assigned case study, and it
provides a thorough, accurate, and detailed justification for
each of the disorders selected.
Feedback:
Points:
Points Range:
16 (16%) - 17 (17%)

The response accurately documents the results of the mental
status exam.
provides an accurate justification for each of the disorders
selected.
Feedback:
Points:

Points Range:
14 (14%) - 15 (15%)
The response documents the results of the mental status exam
with some vagueness or innacuracy.
Response lists at least three different possible disorders for a
differential diagnosis of the patient and provides a justification
for each, but may contain some vagueness or innacuracy.
Feedback:

Points:
Points Range:
0 (0%) - 13 (13%)
of the results of the mental status exam and explanation of the
differential diagnoses. Or the assessment documentation is
missing.
Feedback:
In the Plan section, provide:

• Your plan for psychotherapy
• 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.
• Incorporate one health promotion activity and one patient
education strategy.
Points:
Points Range:
23 (23%) - 25 (25%)
The response provides an evidence-based, detailed, and
appropriate plan for psychotherapy for the patient.

appropriate plan for treatment and management, including
pharmacologic and nonpharmacologic treatments, alternative
therapies, and follow-up parameters. A strong rationale for the
plan is provided that demonstrates critical thinking and content
understanding.
The response includes at least one evidence-based health
promotion activity and one evidence-based patient education
strategy.
Feedback:
Points:
Points Range:
20 (20%) - 22 (22%)

The response provides an evidence-based and appropriate plan
for psychotherapy for the patient.
for treatment and management, including pharmacologic and
up parameters. An adequate rationale for the plan is provided.
The response includes at least one health promotion activity and
one patient education strategy.
Feedback:

Points:
Points Range:
18 (18%) - 19 (19%)
The response provides a somewhat vague or inaccurate plan
The response provides a somewhat vague or inaccurate plan for
treatment and management, including pharmacologic and
nonpharmacologic treatments, alternative therapies, and follow -
up parameters. The rationale for the plan is weak or general.
The response includes one health promotion activity and one
patient education strategy, but it may contain some vagueness
or innacuracy.

Feedback:
Points:
Points Range:
0 (0%) - 17 (17%)
The response provides an incomplete or inaccurate plan for
psychotherapy for the patient.

nonpharmacologic treatments, alternative therapies, and fol low-
up parameters. The rationale for the plan is inaccurate or
missing.
The health promotion and patient education strategies are
incomplete or missing.
Feedback:
• Reflect on this case. 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!), health promotion, and disease prevention that takes
into consideration patient factors (such as age, ethnic group,
etc.), PMH, and other risk factors (e.g., socioeconomic, cultural
background, etc.).

Points:
Points Range:
5 (5%) - 5 (5%)
Reflections are thorough, thoughtful, and demonstrate critical
thinking.
Feedback:

Points:
Points Range:
4 (4%) - 4 (4%)
Reflections demonstrate critical thinking.
Feedback:
Points:

Points Range:
3.5 (3.5%) - 3.5 (3.5%)
Reflections are somewhat general or do not demonstrate
critical thinking.
Feedback:
Points:

Points Range:
0 (0%) - 3 (3%)
Reflections are incomplete, inaccurate, or missing.
Feedback:
Provide at least three evidence-based, peer-reviewed journal
articles or evidenced-based guidelines that relate to this case to
support your diagnostics and differential diagnoses. Be sure
they are current (no more than 5 years old).

Points:
Points Range:
9 (9%) - 10 (10%)
The response provides at least three current, evidence-based
resources from the literature to support the assessment and
diagnosis of the patient in the assigned case study. The
resources reflect the latest clinical guidelines and provide
strong justification for decision making.
Feedback:

Points:
Points Range:
8 (8%) - 8 (8%)
resources from the literature that appropriately support the
assessment and diagnosis of the patient in the assigned case
study.
Feedback:

Points:
Points Range:
7 (7%) - 7 (7%)
Three evidence-based resources are provided to support the
study, but they may only provide vague or weak justification.
Feedback:

Points:
Points Range:
0 (0%) - 6 (6%)
Two or fewer resources are provided to support the assessment
and diagnosis decisions. The resources may not be current or
evidence based.
Feedback:
Written Expression and Formatting - The paper follows correct

APA format for parenthetical/in-text citations and reference list.
Points:
Points Range:
5 (5%) - 5 (5%)
Uses correct APA format with no errors
Feedback:

Points:
Points Range:
4 (4%) - 4 (4%)
Contains 1-2 grammar, spelling, and punctuation errors
Feedback:

Points:
Points Range:
3.5 (3.5%) - 3.5 (3.5%)
Feedback:

Points:
Points Range:
0 (0%) - 3 (3%)
Contains five or more grammar, spelling, and punctuation
errors that interfere with the reader’s understanding
Feedback:
Written Expression and Formatting - English Writing
Standards:
Correct grammar, mechanics, and punctuation

Points:
Points Range:
5 (5%) - 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors
Feedback:

Points:
Points Range:
4 (4%) - 4 (4%)
Contains 1-2 APA format errors
Feedback:

Points:
Points Range:
3.5 (3.5%) - 3.5 (3.5%)
Feedback:
Points:

Points Range:
0 (0%) - 3 (3%)
Contains five or more APA format errors
Feedback:
Show Descriptions

Show Feedback
Create documentation in the Focused SOAP Note Template
about your assigned patient.
• 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,
• Allergies
• ROS
--
Levels of Achievement:
Excellent
90%–100%
14 (14%) - 15 (15%)
The response throughly and accurately describes the patient's
subjective complaint, history of present illness, past psychiatric
history, medication trials and current medications,
psychotherapy or previous psychiatric diagnosis, pertinent

histories, allergies, and review of all systems that would inform
a differential diagnosis.
Good
80%–89%
12 (12%) - 13 (13%)
The response accurately describes the patient's subjective
complaint, history of present illness, past psychiatric history,
medication trials and current medications, psychotherapy or
previous psychiatric diagnosis, pertinent histories, allergies,
and review of all systems that would inform a differential
diagnosis.
Fair
70%–79%
11 (11%) - 11 (11%)
The response describes the patient's subjective complaint,
history of present illness, past psychiatric history, medication
trials and current medications, psychotherapy or previous
psychiatric diagnosis, pertinent histories, allergies, and review

of all systems that would inform a differential diagnosis but is
somewhat vague or contains minor innacuracies.
Poor
0%–69%
0 (0%) - 10 (10%)
of the patient's subjective complaint, history of present illness,
past psychiatric history, medication trials and current
medications, psychotherapy or previous psychiatric diagnosis,
pertinent histories, allergies, and review of all systems that
would inform a differential diagnosis. Or the subjective
documentation is missing.
Feedback:

• 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
--
Excellent
90%–100%
14 (14%) - 15 (15%)
The response thoroughly and accurately documents the patient's
physical exam for pertinent systems. Diagnostic tests and their
results are thoroughly and accurately documented.
Good
80%–89%
12 (12%) - 13 (13%)
The response accurately documents the patient's physical exam
for pertinent systems. Diagnostic tests and their results are
accurately documented.

Fair
70%–79%
11 (11%) - 11 (11%)
Documentation of the patient's physical exam is somewhat
vague or contains minor innacuracies. Diagnostic tests and their
results are documented but contain minor innacuracies.
Poor
0%–69%
0 (0%) - 10 (10%)
The response provides incomplete or inaccurate documentation
of the patient's physical exam. Systems may have been
unnecessarily reviewed. Or the objective documentation is
missing.

Feedback:
• 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
what DSM-5 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.
--
Excellent
90%–100%
18 (18%) - 20 (20%)
The response thoroughly and accurately documents the results
of the mental status exam.

provides a thorough, accurate, and detailed justificatio n for
each of the disorders selected.
Good
80%–89%
16 (16%) - 17 (17%)
The response accurately documents the results of the mental
status exam.
provides an accurate justification for each of the disorders
selected.
Fair
70%–79%
14 (14%) - 15 (15%)

The response documents the results of the mental status exam
with some vagueness or innacuracy.
Response lists at least three different possible disorders for a
differential diagnosis of the patient and provides a justification
for each, but may contain some vagueness or innacuracy.
Poor
0%–69%
0 (0%) - 13 (13%)
of the results of the mental status exam and explanation of the
differential diagnoses. Or the assessment documentation is
missing.
Feedback:

In the Plan section, provide:
• Your plan for psychotherapy
• Your plan for treatment and management, including
alternative therapies. Include pharmacologic and
up parameters as well as a rationale for this treatment and
management plan.
• Incorporate one health promotion activity and one patient
education strategy.
--
Excellent
90%–100%
23 (23%) - 25 (25%)
appropriate plan for psychotherapy for the patient.
appropriate plan for treatment and management, including
pharmacologic and nonpharmacologic treatments, alternative
therapies, and follow-up parameters. A strong rationale for the

plan is provided that demonstrates critical thinking and content
understanding.
The response includes at least one evidence-based health
promotion activity and one evidence-based patient education
strategy.
Good
80%–89%
20 (20%) - 22 (22%)
for treatment and management, including pharmacologic and
up parameters. An adequate rationale for the plan is provided.
The response includes at least one health promotion activity and
one patient education strategy.

Fair
70%–79%
18 (18%) - 19 (19%)
up parameters. The rationale for the plan is weak or general.
The response includes one health promotion activity and one
patient education strategy, but it may contain some vagueness
or innacuracy.
Poor
0%–69%
0 (0%) - 17 (17%)

up parameters. The rationale for the plan is inaccurate or
missing.
The health promotion and patient education strategies are
incomplete or missing.
Feedback:
• Reflect on this case. Discuss what you learned and what
you might do differently. Also include in your reflection a
treatment!), health promotion, and disease prevention that takes
into consideration patient factors (such as age, ethnic group,
etc.), PMH, and other risk factors (e.g., socioeconomic, cultural

background, etc.).--
Excellent
90%–100%
5 (5%) - 5 (5%)
Reflections are thorough, thoughtful, and demonstrate critical
thinking.
Good
80%–89%
4 (4%) - 4 (4%)
Reflections demonstrate critical thinking.
Fair
70%–79%

3.5 (3.5%) - 3.5 (3.5%)
Reflections are somewhat general or do not demonstrate critical
thinking.
Poor
0%–69%
0 (0%) - 3 (3%)
Reflections are incomplete, inaccurate, or missing.
Feedback:
Provide at least three evidence-based, peer-reviewed journal

they are current (no more than 5 years old).--
Excellent
90%–100%
9 (9%) - 10 (10%)
resources from the literature to support the assessment and
diagnosis of the patient in the assigned case study. The
resources reflect the latest clinical guidelines and provide
strong justification for decision making.
Good
80%–89%
8 (8%) - 8 (8%)
resources from the literature that appropriately support the
study.

Fair
70%–79%
7 (7%) - 7 (7%)
Three evidence-based resources are provided to support the
study, but they may only provide vague or weak justification.
Poor
0%–69%
0 (0%) - 6 (6%)
Two or fewer resources are provided to support the assessment
and diagnosis decisions. The resources may not be current or
evidence based.
Feedback:

Written Expression and Formatting - The paper follows correct
APA format for parenthetical/in-text citations and reference
list.--
Excellent
90%–100%
5 (5%) - 5 (5%)
Uses correct APA format with no errors
Good
80%–89%
4 (4%) - 4 (4%)

Fair
70%–79%
3.5 (3.5%) - 3.5 (3.5%)
Poor
0%–69%
0 (0%) - 3 (3%)
Contains five or more grammar, spelling, and punctuation errors
that interfere with the reader’s understanding
Feedback:

Written Expression and Formatting - English Writing Standards:
Correct grammar, mechanics, and punctuation
--
Excellent
90%–100%
5 (5%) - 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors
Good
80%–89%
4 (4%) - 4 (4%)

Fair
70%–79%
3.5 (3.5%) - 3.5 (3.5%)
Poor
0%–69%
0 (0%) - 3 (3%)
Contains five or more APA format errors
Feedback:

Total Points:
100
Name: NRNP_6675_Week5_Assignment_Rubric
Case Study: Sherman Tremaine
© 2021 Walden University, LLC 1
Program Transcript
[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]

Assignment: Focused SOAP Note for Schizophrenia Spectrum,
Other Psychotic, and Medication-Induced Movement Disorders
Psychotic disorders change one’s sense of reality and cause
abnormal thinking and perception. Patients presenting with
psychotic disorders may suffer from delusions or hallucinations
or may display negative symptoms such as lack of emotion or
withdraw from social situations or relationships. Symptoms of
medication-induced movement disorders can be mild or lethal
and can include, for example, tremors, dystonic reactions, or
serotonin syndrome.
For this Assignment, you will complete a focused SOAP note
for a patient in a case study who has either a schizophrenia
spectrum, other psychotic, or medication-induced movement
disorder.
To Prepare
· Review this week’s Learning Resources. Consider the insights
they provide about assessing, diagnosing, and treating
schizophrenia spectrum, other psychotic, and medication-
induced movement disorders.
· Review the Focused SOAP Note template, which you will use
to complete this Assignment. There is also a Focused SOAP
Note Exemplar provided as a guide for Assignment
expectations.
· Review the video, Case Study: Sherman Tremaine. You will
use this case as the basis of this Assignment. In this video, a
Walden faculty member is assessing a mock patient. The patient
will be represented onscreen as an avatar.

· Consider what history would be necessary to collect from this
patient.
· Consider what interview questions you would need to ask this
patient.
The Assignment
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:
· 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 the patient’s mental status examination
results. What were your differential diagnoses? Provide a
minimum of three possible diagnoses with supporting evidence,
and list them in order from highest priority to lowest 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.
· Plan: What is your plan for psychotherapy? What is 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
incorporate 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? Discuss what
your next intervention would be if you were able to follow up

with this patient. Also include in your reflection a discussion
related to legal/ethical considerations (demonstrate critical
thinking beyond confidentiality and consent for treatment!),
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.).
· Provide at least three evidence-based, peer-reviewed journal
they are current (no more than 5 years old)
This is the link to the case study:
Walden University. (2021). Case study: Sherman Tremaine.
Walden University Blackboard. https://class.waldenu.edu
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP
Psychiatric Evaluation Template
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan II
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:
References
© 2021 Walden University

of 3
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.
· 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,
· Allergies
· ROS
Read rating descriptions to see the grading standards!
· 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!
· 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
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
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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