NRNPPRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar

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.

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.
·
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 heal th, 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 manageme nt 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 chroni c
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.

© 2022 Walden University
Page 1 of 3
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 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:
References
© 2021 Walden University
Page 1 of 3
It is important for the PMHNP to have a comprehensive
understanding of mood disorders in order to assess and

accurately formulate a diagnosis and treatment plan for patients
presenting with these disorders. Mood disorders may be
diagnosed when a patient’s emotional state meets the diagnostic
criteria for severity, functional impact, and length of time.
Those with a mood disorder may find that their emotions
interfere with work, relationships, or other parts of their lives
that impact daily functioning. Mood disorders may also lead to
substance abuse or suicidal thoughts or behaviors, and although
they are not likely to go away on their own, they can be
managed with an effective treatment plan and understanding of
how to manage symptoms.
In this Assignment you will assess, diagnose, and devise a
treatment plan for a patient in a case study who is presenting
with a mood disorder.
To Prepare
· Review this week’s Learning Resources. Consider the insights
they provide about assessing, diagnosing, and treating mood
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: Petunia Park. 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.
· Consider patient diagnostics missing from the video:
Provider Review outside of interview:
Temp 98.2
Pulse 90

Respiration 18
B/P 138/88
Laboratory Data Available: Urine drug and alcohol screen
negative. CBC within normal ranges, CMP within normal
ranges. Lipid panel within normal ranges. Prolactin Level 8;
TSH 6.3 (H)
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 symptomatology 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, listed in order from highest to lowest priority.
Compare the
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.
·
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: 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!), social determinates of health, health
promotion, and disease prevention that takes into consideration
Medication Review
Review the FDA approved use of the following medicines
related to treating mood disorders.
Depression
Premenstrual dysphoric disorder
Seasonal affective disorder (MDD with Seasonal Variation)
agomelatine
amitriptyline
amoxapine
aripiprazole
(adjunct)
brexpiprazole (adjunct)bupropion

citalopram
clomipramine
cyamemazine
desipramine
desvenlafaxine
dothiepindoxepin
duloxetine
escitalopram
fluoxetine
fluvoxamine
iloperidone
imipramine
isocarboxazid
ketamine
lithium (adjunct)
l-methylfolate (adjunct)
lofepramine
maprotiline
mianserin
milnacipran
mirtazapine
moclobemide
nefazodone
nortriptyline
paroxetine
phenelzine
protriptyline quetiapine (adjunct)
reboxetine
selegiline
sertindole
sertraline
sulpiride
tianeptine
tranylcypromine
trazodone

trimipramine
venlafaxine
vilazodone
vortioxetine
citalopram
desvenlafaxine
duloxetin
eescitalopram
fluoxetin
eparoxetine
pepexev
sarafe,
sertraline
venlafaxine
Bupropion HCL extended-release
Bipolar depression
Bipolar disorder (mixed Mania/Depression
Bipolar maintenance
Mania
lithium (used with lurasidone)
lurasidone
olanzapine-fluoxetine combination (symbyax)
quetiapine
valproate (divalproex) (used with lurasidone)
aripiprazole
asenapine
carbamazepine
olanzapine
ziprasidone
aripiprazole
lamotrigine
lithium
olanzapine

aripiprazole
asenapine
carbamazepine
lithium
olanzapine
quetiapine
risperidone
valproate (divalproex)
ziprasidone
Mood Disorders in Adults
I am finally doing everything right. I stayed up all night
studying for my final exams and even managed to clean out my
closet and order a whole new bedroom from the internet. I know
I will ace all my exams. Nothing can go wrong like they did a
few months ago. I was so low and was sleeping all the time. I
did not think I would ever be happy again, but now I know I can
do anything.
—Jessica, age 22
Patients presenting with mood disorders may find that their
moods impact their ability to function or that their moods are
not consistent with their circumstances. Bipolar and related
disorders are one category of mood disorders. They affect
nearly 3% of the U.S. population each year (Depression and
Bipolar Support Alliance, n.d.). Although being relatively rare
in terms of lifetime prevalence, bipolar disorder is burdensome
to the individual and health care system because of its early
onset, severity, and chronic nature. The average age of onset is
around 25 and it affects men and women equally.
The importance of evidence-based intervention for treatment in
persons with mood disorders cannot be underestimated.
Unstable moods can result in repeat chronic hospitalizations and
profound life disruption. Mood disorders are a leading cause of

disability worldwide and can contribute to suicide (World
Health Organization, 2020). Practitioners should understand
that developing a good rapport and relationship with the patient
can make a significant difference in the course, symptom
management, and stability of the patient.Assignment: Assessing,
Diagnosing, and Treating Adults With Mood Disorders
It is important for the PMHNP to have a comprehensive
understanding of mood disorders in order to assess and
accurately formulate a diagnosis and treatment plan for patients
presenting with these disorders. Mood disorders may be
diagnosed when a patient’s emotional state meets the diagnostic
criteria for severity, functional impact, and length of time.
Those with a mood disorder may find that their emotions
interfere with work, relationships, or other parts of their lives
that impact daily functioning. Mood disorders may also lead to
substance abuse or suicidal thoughts or behaviors, and although
they are not likely to go away on their own, they can be
managed with an effective treatment plan and understanding of
how to manage symptoms.
In this Assignment you will assess, diagnose, and devise a
treatment plan for a patient in a case study who is presenting
with a mood disorder.To Prepare
· Review this week’s Learning Resources. Consider the insights
they provide about assessing, diagnosing, and treating mood
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: Petunia Park. 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.
· Consider patient diagnostics missing from the video:
Provider Review outside of interview:
Temp 98.2
Pulse 90
Respiration 18
B/P 138/88
Laboratory Data Available: Urine drug and alcohol screen
negative. CBC within normal ranges, CMP within normal
ranges. Lipid panel within normal ranges. Prolactin Level 8;
TSH 6.3 (H)
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 symptomatology 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, listed in order from highest to lowest priority.
Compare the

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.
·
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: 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!), social determinates of health, health
promotion, and disease prevention that takes into consideration
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).
Case Study: Petunia Park

© 2020 Walden University 1
Program Transcript
[MUSIC PLAYING]
DR. MOORE: Hi. Good afternoon. My name is Dr. Moore. Am I
understanding you're
here for a mental health assessment today?
PETUNIA PARK: That's right.
DR. MOORE: OK. So to make sure I have the right patient and
the right chart, can you
tell me your name and your date of birth?
PETUNIA PARK: Yes. I'm Petunia Park. My birthday is July 1,
1995.
DR. MOORE: And can you tell me what today's date is?
PETUNIA PARK: So it's December 1.
DR. MOORE: Do you know the year?
PETUNIA PARK: 2020.
DR. MOORE: And what day of the week is this?
PETUNIA PARK: It's Tuesday.
[CHUCKLING]

DR. MOORE: And do you know where we are today?
PETUNIA PARK: Yes I am here in the beautiful, sunny office
at the clinic.
DR. MOORE: OK, great. Thank you. So can you tell me a little
bit about why you're here
today? What brings you here today?
PETUNIA PARK: Yes. So I have a history of taking
medications and then stopping
them. I don't think I need them. I really feel like the medication
squashes who I am.
DR. MOORE: OK, OK. So I'm going to be able to help you with
that. But to begin, I'm
going to ask you some questions about your family. I'm going to
ask you some history-
type questions. I'm going to ask you some symptoms that you
might be having. And all
of these questions are going to help me work with you on a
treatment plan, OK? So I
would like to begin with, when was the first time that you ever
had any mental health or
substance use treatment in your life?
PETUNIA PARK: OK. Well, when I was a teenager, my mom
put me in the hospital after
I went four or five days without sleeping. I think I may have

been hearing things at that
time. [CHUCKLES] I think they started me on some medication,
but I'm not sure.
DR. MOORE: Oh, OK so you were hospitalized. How many
times have you been
hospitalized for mental health?
PETUNIA PARK: Oh, I've been hospitalized about four times.
The last time was this
past spring. No detox or residential rehabs, though.
DR. MOORE: OK, good. Were any of these hospitalizations due
to any suicide
gestures?
PETUNIA PARK: One was in 2017. I overdosed on Benadryl,
but I've not had those
thoughts since then.
DR. MOORE: Well, I'm very glad to hear that you've not had
any of those thoughts
since then. And I'm glad that you turned out OK from that
overdose. I'm glad that you're
here today. Can you tell me a little bit about what you've been
diagnosed with during
your past treatments?
PETUNIA PARK: Well, I think depression, and anxiety, had
some even say maybe
bipolar.
DR. MOORE: OK, and what medications have you been tried on
before for those
illnesses? And if you can remember, what was your reactions to
those medications?

PETUNIA PARK: Oh, let's see. Oh, I took Zoloft, and that made
me feel really high.
[CHUCKLES] I couldn't sleep. My mind was racing, and then I
took risperidone. That
made me gain a bunch of weight. Seroquel gave me weight, too.
I took Klonopin, and
that seems to slow me down some.
I really can't remember the others. I think the one I just stopped
taking was helping. It
started with an L, I think. I don't really remember the name, but
it squashed me in
creativity.
DR. MOORE: OK, well, we're going to try to help you find
some medication that doesn't
make you feel squashed or have any of those negative side
effects today. But in order
to do that, I need some more information. And the next
questions I'm going to ask you
are about substances you may have used. And I want you to
know that you don't get in
trouble in here if you've used some of these substances. It really
just helps me to make
sure that what's in your system that could be impacting your
neurochemistry. And when
we do talk about medications, so I don't give you something that
would negatively
interact with something you may be using, OK? So do you--
PETUNIA PARK: OK.

DR. MOORE: --use any nicotine?
PETUNIA PARK: Yes. I smoke about a pack a day, and I'm not
going to quit for you,
either. [CHUCKLES] Oh.
DR. MOORE: That's OK, that's OK. And what about alcohol?
When was your last drink
of alcohol?
PETUNIA PARK: When I was 19 because alcohol and me do
not work well together.
[CHUCKLES]
DR. MOORE: OK, and what about any marijuana? When was
your last use of any
marijuana?
PETUNIA PARK: Oh no. I tried that once and got really
paranoid.
DR. MOORE: OK. What about any last use of cocaine?
PETUNIA PARK: Never.
DR. MOORE: Last use of any stimulants or methamphetamines?
DR. MOORE: What about any huffing or inhalants?

DR. MOORE: OK, have you used anything like Klonopin or
Xanax, any of those
sedative medications?
DR. MOORE: All right, good. What about any hallucinogenics
like LSD, or PCP, or
mushrooms?
PETUNIA PARK: No, never.
DR. MOORE: Wonderful. OK, what about any use of pain pills
or opiate medications?
Anything prescribed or anything you've obtained from the
street?
PETUNIA PARK: No, never.
DR. MOORE: Good. And anything synthetic like Spice, or
ecstasy, Bath Salts, Mollies,
anything like that?
DR. MOORE: Oh, wonderful. Well, I'm glad to hear that. You
know those things aren't
good for your brain. So I encourage you to continue to stay

away from those things.
Have you ever had any blackouts or seizures from drugs or
alcohol? Or seen things that
you weren't sure were there?
DR. MOORE: Good. What about any legal issues or any DUIs?
DR. MOORE: OK. Good, good. All right, so I'm just going to
ask a little bit about your
family right now. Any blood relatives have any mental health or
substance abuse
issues?
PETUNIA PARK: Yeah, well, well, why would you ask that?
It's not your business.
DR. MOORE: Right. I could see where you might find that
wouldn't be any my business.
But really, sometimes these issues can be genetic. They're alarm
behaviors. So my
understanding of your family helps me to understand you.
PETUNIA PARK: Huh. Well, my mother was seen as crazy. I
think they said she had
bipolar or something. And my father went to prison for drugs.
And well, we haven't
heard, or seen, or heard from him in 8 or 10 years. My brother,
while I think he's a little
schizo, but he hasn't ever went to the doctor. Nobody else with
anything.
DR. MOORE: OK. So that sounds like it must be tough growing

up not seeing your
father and having some of those issues in your family. But any
family, blood relatives
commit suicide?
PETUNIA PARK: Well, my mom tried, but nobody really did it,
you know?
DR. MOORE: OK. Have you ever done anything like that, or
anything like cut on
yourself, burn yourself?
PETUNIA PARK: I already told you, I tried to kill myself. Why
ask me that again? No, I'm
not going to kill myself or anyone else, and I don't cut myself.
DR. MOORE: OK. Well, I'm glad to hear that. And I want you
to know that I am here for
you, and we most certainly will make sure you have a crisis like
number at the end of
this session if you do have those thoughts in the future. So I'm
glad to hear that you
don't have those thoughts today. OK. What type of medical
issues do you have?
PETUNIA PARK: Oh, hoo. Let's see. I have a thyroid issue that
I take some medicine
for, that hypothyroidism. And I take a birth control pill for
polycystic ovaries.

DR. MOORE: OK, when was your last menses?
PETUNIA PARK: Oh, well I have a regular one each month. So
let's see. It was last
month sometime.
DR. MOORE: OK, so any chance that you're pregnant?
PETUNIA PARK: [LAUGHS] Lordy, no. I may have a lot of sex
around, but I'm safe.
DR. MOORE: Hm. You "have a lot of sex around." Can you
maybe tell me what that
means?
PETUNIA PARK: Well, it's exciting and thrilling to find new
people to explore sex with. It
helps me keep my moods high, high, high. [CHUCKLES]
DR. MOORE: OK, so that makes you feel really high and kind
of what, OK?
PETUNIA PARK: Oh yeah.
DR. MOORE: So who raised you?
PETUNIA PARK: My mom and my older brother, mainly.
DR. MOORE: And who do you live with now?
PETUNIA PARK: Well, I live with my boyfriend. And
sometimes, stay with my mom
when he gets mad at me for sleeping around some.
DR. MOORE: So that's created some issues in your relationship,

I see. OK. Are you
single, married, widowed, or divorced?
PETUNIA PARK: I've never been married.
DR. MOORE: OK. Do you have any children?
PETUNIA PARK: No.
DR. MOORE: All right. Are you working?
PETUNIA PARK: Yes, I work part time at my aunt's bookstore.
She's more tolerant of
the days I don't come in from feeling too depressed.
DR. MOORE: OK, so I hear some, maybe, feelings of
depressed. OK. What is your
level of education?
PETUNIA PARK: Oh, I'm in vo-tech school right now for
cosmetology. I'm going to do
makeup for movie stars. [CHUCKLES]
DR. MOORE: Oh, that sounds really wonderful. OK, so but
what about now? What do
you do for fun now?
PETUNIA PARK: Well, I am writing my life story, and it's
going to be published. I also

paint like Picasso. I'm going to sell those paintings to movie
stars, too.
DR. MOORE: Well, that's wonderful. Maybe someday you can
show me your paintings
as well. OK, have you ever been arrested or convicted for
anything?
PETUNIA PARK: No. The police did pick me up and take me to
the hospital once. I
didn't have much sleep that week. And they said I was dancing
around in my nightgown
in a field with my guitar. I really don't remember much of that,
though. I think maybe my
mom made up that story against me because she wanted me to
go back to my
boyfriend's house.
DR. MOORE: OK, so that was one of your hospitalizations that
we talked about earlier.
OK, what about any history of trauma with childhood or adult?
Any kind of physical,
sexual, emotional abuse?
PETUNIA PARK: Well, my dad was pretty hard on us when he
was around. But he
didn't really touch us or anything. More just yelled at us a lot.
DR. MOORE: OK. All right, so I've gathered some history here.
Now, I want to get into
more of some of the symptoms that brought you in to see me
today. So you mentioned
before that sometimes your depression keeps you from working
at your aunt's
bookstore. Can you tell me a little bit more about what that
looks like for you?

PETUNIA PARK: Well, about four or five times a year, I have
these times when I just
don't want to get out of bed. I have no energy, no motivation to
do anything. I just can't
feel any interest in my creativity. I feel like I'm not worth
anything because I feel that
creativity slipping away.
So this is usually happening after I've been up for five days
working hard on my works
with my writing, painting, and music. Everyone says I'm
depressed, but I'm not sure. It
could be that I'm just exhausted from working so hard.
DR. MOORE: OK, so I hear you talking about these creativity
episodes right before you
crash. Per se, this depression. Tell me a little bit more about
those episodes. What do
those look like for you?
PETUNIA PARK: Oh, I love those times. Those are the reasons
I don't always take my
medication because I feel like I'm squashed. I have lots of
energy to do a lot of things. I
can go four or five days with very little sleep. I get lots of
things done, but my friends tell
me I talk too much and appear scattered.

[SIGHS] They're just jealous of all the accomplishments I'm
getting done. These are the
times I look to explore my mind and body with feeling good
through sex with other
people.
DR. MOORE: OK, how long do those episodes last typically
when you have them?
PETUNIA PARK: About a week.
DR. MOORE: About a week. OK. So I want to ask a little bit
more about some other
symptoms that maybe we haven't talked about. Do you feel like
you worry a lot or have
any kind of anxiety and panic symptoms?
PETUNIA PARK: No, no no. I'm not a worry.
DR. MOORE: OK, do you do anything that you feel like you
have to do repetitively over
and over? And if you can't do them, you feel like the end of the
world is coming?
Something like maybe count on threes or wash your hands 20
times? Anything like
that?
PETUNIA PARK: [LAUGHS] No, no. I don't have OCD, if
that's what you're asking.
DR. MOORE: OK, what about hearing or seeing things you're
not sure others see or
hear? Anything like that?
PETUNIA PARK: Not right now. It's been a couple of months
since that happened.

Sometimes when I'm not sleeping good, I hear voices telling me
how great and
wonderfully talented I am.
DR. MOORE: OK. So, but no voices right now?
PETUNIA PARK: No.
DR. MOORE: OK, good. What about your appetite? How's your
appetite?
PETUNIA PARK: Well, when I'm really creative, I'm too busy
to eat. And when I'm
crashing and resting, I eat everything in sight.
DR. MOORE: OK, so what about your sleep? On average, how
much time do you think
you sleep in a whole 24-hour period? And do you have any bad
dreams?
PETUNIA PARK: No bad dreams. Most of the time, I get about
five or six hours. When
I'm creative, I'm lucky to get three hours and a whole week.
Ugh. And when I'm crashed,
I sleep about 12 or 16 hours a day.
DR. MOORE: OK, wonderful. So this is great. I have a lot of
information from you that I
think we will be able to come up with a treatment plan and

maybe find some medication
that's going to help you feel better without you feeling so
squashed and having negative
side effects, but really help you be able to function through the
day.
[MUSIC PLAYING]

NRNPPRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar

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