Required Media· Centers for Disease Control and Prevention. (202.docx

Required Media
· Centers for Disease Control and Prevention. (2020, April 3).
Adverse childhood experiences (ACEs) Links to an
external site.[Video].
https://www.cdc.gov/violenceprevention/aces/index.html
· Dartmouth Films. (2018, September 25).
Resilience Links to an external site.[Video]. YouTube.
https://www.youtube.com/watch?v=bAXZVYDNURY
· NCTSN. (2007).
The promise of trauma-focused therapy for childhood
sexual abuse Links to an external site. [Video].
https://www.nctsn.org/resources/promise-trauma-focused-
therapy-childhood-sexual-abuse-video
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP
Psychiatric Evaluation Template
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.
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 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.
© 2022 Walden University
Page 1 of 3
[MUSIC PLAYING] DR. JENNY: Hi there. My name is Dr.
Jenny. Can you tell me your
name and how old you are? DEV CORDOBA: My name is Dev,
and I am seven years old. DR. JENNY: Wonderful. Dev, can
you tell me what
the month and the date is? And where are we right now? DEV
CORDOBA: Today
is St. Patrick's Day. It's March 17th. DR. JENNY: Do you
know where we are? DEV CORDOBA: We're
at the school. DR. JENNY: Good. Did your mom tell you why
you're here today to see me? DEV CORDOBA: She
thought you were going to help me be better. DR. JENNY: Yes,
I
am here to help you. Have you ever come to see
someone like me before, or talked to someone like
me before to help you with your mood? DEV CORDOBA: No,
never. DR. JENNY: OK. Well, I would like
to start with getting to know you a little bit
better, if that's OK. What do you like to do for
fun when you're at home? DEV CORDOBA: Oh, I have a dog.
His name is Sparky. We play policeman in my room. And I have
LEGOs, and I could
build something if you want. DR. JENNY: I would love to see
what you build with your LEGOs. Maybe you can bring that
in for me next appointment. Who lives in your home? DEV
CORDOBA: My mom and my
baby brother and Sparky. DR. JENNY: Do you help
your mom with your brother? DEV CORDOBA: No. His breath

smells like
bad milk all the time. [CHUCKLES] And he
cries a lot, and my mom spends more time with him. DR.
JENNY: So how do you
feel most of the time? Do you feel sad or
worried or mad or happy? DEV CORDOBA: Worried. DR.
JENNY: What types of
things do you worry about? DEV CORDOBA: I don't
know, just everything. I don't know. DR. JENNY: OK. So your
mom tells me you also
have a lot of bad dreams. Can you tell me a little
more about your bad dreams, like maybe what they're
about, how many nights you might have them? DEV
CORDOBA: I dream
a lot that I'm lost, that I can't find my mom
or my little brother. They seem like they happen
almost every night, but maybe not some nights. DR. JENNY:
Now that
must feel horrible. Have you ever been lost before
when maybe you weren't asleep? DEV CORDOBA: Oh, no. No.
And I don't like the dark. My mom puts me in a night
light with the door open, so I know she's really there. DR.
JENNY: That seems like
that probably would help. Do you like to go to school? Or
would you rather not go? DEV CORDOBA: I worry
about by mom and brother when I'm at school. All I can think
about
is what they're doing, and if they're OK. And besides, nobody
likes me there. They call me Mr. Smelly. DR. JENNY: Well.
That's not nice at all. Why do you feel
they call you names? DEV CORDOBA: I don't know. But my
mom says it's because
I won't take my baths. [SIGHS] She tells
me to, and it-- and I have night accidents. DR. JENNY: Oh, how
does
that make you feel? DEV CORDOBA: Sad and really bad. They

don't know how it feels for
their daddy to never come home. What if my mom
doesn't come home too? DR. JENNY: Yes, you seem
to worry about that a lot. Does this worry stop you from
being able to learn in school? DEV CORDOBA: Well, [SIGHS]
my teacher is, all the time, telling me to sit
down and focus. And I get in trouble for
[SIGHS] looking out the window. And she moved my
chair beside her desk, but I don't mind because
Billy leaves me alone now. DR. JENNY: Billy. Have you ever
hit
Billy or anyone else? DEV CORDOBA: No, but I
did throw my book at him. DR. JENNY: Hmm. DEV
CORDOBA: [CHUCKLES] DR. JENNY: What about yourself?
Have you ever hit yourself or
thought about doing something to hurt yourself? DEV
CORDOBA: No. DR. JENNY: OK. Well, Dev, I would like
to talk to your mom now. We're going to work
together, and we're going to help you feel
happier, less worried, and be able to
enjoy school more. Is that OK? DEV CORDOBA: Yes. Thank
you. MISS CORDOBA: Hi. DR. JENNY: Thank you, Miss
Cordoba, for bringing in Dev. I feel we can help him. So tell
me, what is your
main concerns for Dev? MISS CORDOBA: [SIGHS] Well,
he just seems so anxious and worried all the time, silly
things like I'm going to die, or I won't pick
him up from school. He says I love his
brother more than him. He'll throw things
around the house, and gets in trouble at
school for throwing things. He has a difficult
time going to sleep. He wants his lights on, doors
open, gets up frequently. And he's all the time
wanting to come home from school, claims stomach
aches, and headaches almost daily. He won't eat. He's lost three
pounds

in the past three weeks. Our pediatrician sent us to
you because he doesn't believe anything is physically wrong.
Oh, and I almost forgot. He still wets the bed at night. [SIGHS]
We've tried everything. His pediatrician
did give him DDVAP, but it doesn't seem to help. DR. JENNY:
Hmm. OK. Can you tell me,
any blood relatives have any mental health
or substance use issues? MISS CORDOBA: No, not really. DR.
JENNY: What
about his father? He said that he never came home? MISS
CORDOBA: Oh, yes. His father was deployed with
the military when Dev was five. I told Dev he was on vacation.
I didn't know what to tell him. I thought he was too
young to know about war. And his father was
killed, so Dev still doesn't understand that his
father didn't just leave him. [SIGHS] I just feel so guilty
that all of this is my fault. DR. JENNY: Miss Cordoba,
you did the right thing by bringing in Dev. We can help you
with him. MISS CORDOBA: Oh, thank you. [MUSIC
PLAYING]
NRNP_6675_Week3_Assignment_Rubric
NRNP_6675_Week3_Assignment_Rubric
Criteria
Ratings
Pts
This criterion is linked to a Learning OutcomeCreate
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
15 to >13.0 pts
Excellent 90%–100%

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.
13 to >11.0 pts
Good 80%–89%
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.
11 to >10.0 pts
Fair 70%–79%
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.
10 to >0 pts
Poor 0%–69%
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.
15 pts
This criterion is linked to a Learning OutcomeIn 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
15 to >13.0 pts
The response thoroughly and accurately documents the patient's
physical exam for pertinent systems. Diagnostic tests and their
results are thoroughly and accurately documented.
13 to >11.0 pts
Good 80%–89%
The response accurately documents the patient's physical exam
for pertinent systems. Diagnostic tests and their results are
accurately documented.
11 to >10.0 pts
Fair 70%–79%
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.
10 to >0 pts
Poor 0%–69%
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.
15 pts
This criterion is linked to a Learning OutcomeIn 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.
20 to >17.0 pts

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.
17 to >15.0 pts
Good 80%–89%
The response 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 an accurate justification for each of the
disorders selected.
15 to >13.0 pts
Fair 70%–79%
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.
13 to >0 pts
Poor 0%–69%
The response provides an incomplete or inaccurate description
of the results of the mental status exam and explanation of the
differential diagnoses. Or the assessment documentation is
missing.
20 pts
This criterion is linked to a Learning OutcomeIn 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.
25 to >22.0 pts
The response provides an evidence-based, detailed, and
appropriate plan for psychotherapy for the patient.... The
response provides an evidence-based, detailed, and 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.
22 to >19.0 pts
Good 80%–89%
The response provides an evidence-based and appropriate plan
for psychotherapy for the patient.... The response provides an
evidence-based and appropriate plan for treatment and
management, including pharmacologic and nonpharmacologic
treatments, alternative therapies, and follow-up parameters. An
adequate rationale for the plan is provided.... The response
includes at least one health promotion activity and one patient
education strategy.
19 to >17.0 pts
Fair 70%–79%
The response provides a somewhat vague or inaccurate plan for
psychotherapy for the patient.... 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.
17 to >0 pts

Poor 0%–69%
The response provides an incomplete or inaccurate plan for
psychotherapy for the patient.... The response provides an
incomplete or inaccurate plan for treatment and management,
including pharmacologic and nonpharmacologic treatments,
alternative therapies, and follow-up parameters. The rationale
for the plan is inaccurate or missing.... The health promotion
and patient education strategies are incomplete or missing.
25 pts
This criterion is linked to a Learning Outcome• Discussion
include what may be done differently with this patient if student
conducted the session again. Discussed the next intervention if
you could follow up with this patient. The discussion was
related to legal/ethical considerations (demonstrated critical
thinking beyond confidentiality and consent for treatment!),
social determinates of health, health promotion, and disease
prevention that take into consideration patient factors (such as
age, ethnic group, etc.), PMH, and other risk factors (e.g.,
socioeconomic, cultural background, etc.).
5 to >4.0 pts
Reflections are thorough, thoughtful, and demonstrate critical
thinking. Reflections contain a discussion of all elements
described within assignment directions.
4 to >3.5 pts
Good 80%–89%
Reflections demonstrate critical thinking. Reflections contain 2
out of 3 (legal/ethical considerations, social determinate of
health, health promotion) with consideration of patient factors
and risk factors.
3.5 to >3.0 pts
Fair 70%–79%
Reflections are somewhat general or do not demonstrate critical
thinking. Reflections contain 2 out of 3 (legal/ethical
considerations, social determinate of health, health promotion)

without consideration of patient factors and risk factors.
3 to >0 pts
Poor 0%–69%
Reflections are incomplete, inaccurate, or missing.
5 pts
This criterion is linked to a Learning OutcomeProvide 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).
10 to >8.0 pts
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.
8 to >7.0 pts
Good 80%–89%
The response provides at least three current, evidence-based
resources from the literature that appropriately support the
assessment and diagnosis of the patient in the assigned case
study.
7 to >6.0 pts
Fair 70%–79%
Three evidence-based resources are provided to support the
assessment and diagnosis of the patient in the assigned case
study, but they may only provide vague or weak justification.
6 to >0 pts
Poor 0%–69%
Two or fewer resources are provided to support the assessment
and diagnosis decisions. The resources may not be current or
evidence based.
10 pts

This criterion is linked to a Learning OutcomeWritten
Expression and Formatting - The paper follows correct APA
format for parenthetical/in-text citations and reference list.
5 to >4.0 pts
Uses correct APA format with no errors
4 to >3.5 pts
Good 80%–89%
Contains 1-2 APA format for parenthetical/in-text citations and
reference list errors
3.5 to >3.0 pts
Fair 70%–79%
Contains 3-4 APA format for parenthetical/in-text citations and
reference list errors
3 to >0 pts
Poor 0%–69%
Contains five or more APA format for parenthetical/in-text
citations and reference list errors
5 pts
This criterion is linked to a Learning OutcomeWritten
Expression and Formatting - English Writing Standards: Correct
grammar, mechanics, and punctuation
5 to >4.0 pts
Uses correct grammar, spelling, and punctuation with no errors
4 to >3.5 pts
Good 80%–89%
Contains 1-2 grammar, spelling, and punctuation format errors
3.5 to >3.0 pts
Fair 70%–79%
Contains 3-4 grammar, spelling, and punctuation format errors
3 to >0 pts
Poor 0%–69%
Contains five or more grammar, spelling, and
punctuation format errors that interfere with the reader’s

understanding
5 pts
Total Points: 100
ASSIGNMENT
Anxiety disorders provide a good opportunity to take a close
look at the nature/nurture debate as well as the
gene/environment interactions that influence the nervous system
and neurochemistry. A significant part of most of Sigmund
Freud’s theories, the concept of anxiety has been debated and
discussed over many years in the psychiatric literature. While
Freud’s theories focused on the “mind” and the unconscious,
another way to look at anxiety is with Hans Selye’s concept of
“fight or flight” in which the sympathetic nervous system
activates a response to stress. As you explore anxiety disorders,
you will notice that no two cases of anxiety are the same.
Obsessive-compulsive disorder is characterized by the presence
of obsessive thoughts, which manifest as persistent thoughts,
images, or even “urges.” The only way that the individual can
disperse the anxiety of these persistent thoughts/images and
urges is to perform a behavior (the compulsion). The
compulsion could be checking things, counting, reciting a silent
prayer, or repeating a number of phrases. The disorder becomes
so pervasive that the person can spend a significant amount of
time each day attending to the compulsion in order to relieve
the anxiety caused by the obsession.
Although trauma and stressor-related disorders stem from
exposure to a traumatic or stressful event, not all exposures to
trauma or stress will result in a disorder. However, following
these types of events, patients may report symptoms that
interfere with their ability to function well in one or more areas
of their life, such as flashbacks, nightmares, or intense
psychological or physiological distress.
This week, you will explore evidence-based treatment methods

for patients with anxiety, obsessive-compulsive, as well as
trauma and stressor-related disorders.
FOCUSED SOAP NOTE FOR ANXIETY, PTSD, AND OCD
In assessing patients with anxiety, obsessive-compulsive, and
trauma and stressor-related disorders, you will continue the
practice of looking to understand chief symptomology in order
to develop a diagnosis. With a differential diagnosis in mind,
you can then move to a treatment and follow-up plan that may
involve both psychopharmacologic and psychotherapeutic
approaches.
In this Assignment, you use a case study to develop a focused
SOAP note based on evidence-based approaches.
TO PREPARE
· Review this week’s Learning Resources. Consider the insights
they provide about assessing and diagnosing anxiety, obsessive
compulsive, and trauma-related 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: Dev Cordoba. 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,
listed 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 could 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 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).

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