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 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. (See attached documents)
· Review the video,
Case Study: Sherman Tremaine. You will use this case as the basis of this Assignment. – Transcript below
· 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 .
FOCUSED SOAP NOTE FOR SCHIZOPHRENIA SPECTRUM, OTHER PSYCHOTIC, AND.docx
1. 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 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. (See attached documents)
· Review the video,
Case Study: Sherman Tremaine. You will use this case
as the basis of this Assignment. – Transcript below
· 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
2. 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.
3. · 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
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: Sherman Tremaine - Transcript
Walden University. (2021).
Case study: Sherman Tremaine. Walden University
Canvas. https://waldenu.instructure.com
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
4. 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.
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.
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
5. 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?
6. 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.
7. DR. MOORE: OK. So, thank you for answering those questions
for me. Now, let's talk about how I can best help you.
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NURS_6003_Module03_Week05_Assignment_Rubric
Criteria Ratings Pts
25 pts
20 pts
Using the Week 3
Part 3, section of
your Academic
Success and
Professional
Development Plan
Template complete
Step 1. Conduct an
analysis of the
elements of the
research article you
identified. Be sure to
include the
following:· The topic
of interest you have
selected. · Correctly
formatted APA
citation of the article
8. you selected, along
with link or search
details. · Identify one
or more professional
practice uses of the
theories/concepts
presented in the
article.
25 to >22.0 pts
Excellent
The response
clearly identifies
the topic of
interest selected.
... The response
accurately and
completely
provides a citation
of the article
selected,
including an
accurate and
complete link or
thorough search
details. ... The
response clearly
identifies and
describes in detail
a professional
practice use of
the
theories/concepts
presented in the
article.
9. 22 to >19.0 pts
Good
The response
partially identifies
the topic of
interest selected.
... The response
provides a partial
citation of the
article selected,
including a partial
link or search
details. ... The
response partially
identifies and
describes a
professional
practice use of
the
theories/concepts
presented in the
article.
19 to >17.0 pts
Fair
The response
vaguely identifies
the topic of
interest selected.
... The response
vaguely or
inaccurately
provides a citation
of the article
selected,
including vague
10. or inaccurate
search details. ...
The response
vaguely or
inaccurately
identifies and
describes a
professional
practice use of
the
theories/concepts
presented in the
article.
17 to >0 pts
Poor
The response
vaguely and
inaccurately
identifies the topic
of interest
selected or is
missing. ... The
response vaguely
and inaccurately
provides a citation
of the article
selected,
including vague
and inaccurate
search details, or
is missing. ... The
response vaguely
and inaccurately
identifies and
describes a
11. professional
practice use of
the
theories/concepts
presented in the
article or is
missing.
Analysis of the
article using the
Research Analysis
Matrix section of the
template
for:Strengths of the
ResearchLimitations
of the
ResearchRelevancy
to the Topic of
Interest. · Write a
one-paragraph
justification
explaining whether
or not you would
recommend the use
of this article to
inform professional
practice.
20 to >17.0 pts
Excellent
The response
clearly and
accurately
provides a detailed
analysis of the
article using the
12. Research Analysis
Matrix section of
the template. ...
The response
clearly and
accurately
explains in detail
the justification of
whether to
recommend the
use of the article to
inform professional
practice.
17 to >15.0 pts
Good
The response
provides a partial
analysis of the
article using the
Research Analysis
Matrix section of
the template. ...
The response
partially explains
the justification of
whether or not to
recommend the
use of the article
to inform
professional
practice.
15 to >13.0 pts
Fair
The response
13. provides a vague
or inaccurate
analysis of the
article using the
Research Analysis
Matrix section of
the template. ...
The response
vaguely or
inaccurately
explains the
justification of
whether or not to
recommend the
use of the article
to inform
professional
practice.
13 to >0 pts
Poor
The response
provides a
vague and
inaccurate
analysis of the
article using the
Research
Analysis Matrix
section of the
template or is
missing. ... The
response
vaguely and
inaccurately
explains the
14. justification of
whether or not
to recommend
the use of the
article to inform
professional
practice or is
missing.
Criteria Ratings Pts
45 pts
5 pts
Part 3, Step 2: Write
a 2-3 paragraph
summary that you
will add to your
Academic Success
and Professional
Development Plan
that includes the
following: · Describe
your approach to
identifying and
analyzing peer-
reviewed research·
Identify at least two
strategies that you
would use that you
found to be effective
in finding peer-
reviewed research. ·
15. Identify at least one
resource you intend
to use in the future
to find peer-reviewed
research.
45 to >40.0 pts
Excellent
The response
clearly and
accurately
describes in detail
the approach to
identifying and
analyzing peer-
reviewed
research. The
response clearly
identifies and
accurately
describes in detail
at least two
strategies used to
be effective in
finding peer-
reviewed
research. ... The
response clearly
identifies and
accurately
describes in detail
at least one
resource you
intend to use in
the future to find
peer-reviewed
16. research.
40 to >35.0 pts
Good
The response
partially describes
the approach to
identifying and
analyzing peer-
reviewed
research. The
response partially
identifies and
describes at least
two strategies
used to be
effective in finding
peer-reviewed
research. ... The
response partially
identifies and
describes in detail
at least one
resource you
intend to use in
the future to find
peer-reviewed
research.
35 to >31.0 pts
Fair
The response
vaguely or
inaccurately
describes the
approach to
17. identifying and
analyzing peer-
reviewed
research. The
response vaguely
or inaccurately
identifies and
describes at least
two strategies
used to be
effective in finding
peer-reviewed
research. ... The
response vaguely
or inaccurately
identifies
describes in detail
at least one
resource you
intend to use in
the future to find
peer-reviewed
research.
31 to >0 pts
Poor
The response
vaguely and
inaccurately
describes the
approach to
identifying and
analyzing peer-
reviewed
research or is
missing. The
18. response
vaguely and
inaccurately
identifies and
describes at
least two
strategies used
to be effective
in finding peer-
reviewed
research or is
missing. ... The
response
vaguely or
inaccurately
identifies
describes in
detail or is
missing at least
one resource
you intend to
use in the future
to find peer-
reviewed
research.
Written Expression
and Formatting -
Paragraph
Development and
Organization:
Paragraphs make
clear points that
support well
developed ideas,
flow logically, and
19. demonstrate
continuity of ideas.
Sentences are
carefully focused--
neither long and
5 to >4.0 pts
Excellent
Paragraphs and
sentences follow
writing standards
for flow,
continuity, and
clarity.
4 to >3.0 pts
Good
Paragraphs and
sentences follow
writing standards
for flow, continuity,
and clarity 80% of
the time.
3 to >2.0 pts
Fair
Paragraphs and
sentences follow
writing standards
for flow, continuity,
and clarity 60%-
79% of the time.
2 to >0 pts
Poor
Paragraphs and
20. sentences follow
writing standards
for flow,
continuity, and
clarity < 60% of
the time.
Total Points: 100
Criteria Ratings Pts
5 pts
rambling nor short
and lacking
substance. which
delineates all
required criteria.
Written Expression
and Formatting -
English writing
standards: Correct
grammar,
mechanics, and
proper punctuation
5 to >4.0 pts
Excellent
Uses correct
grammar,
spelling, and
punctuation with
no errors.
21. 4 to >3.0 pts
Good
Contains a few
(1-2) grammar,
spelling, and
punctuation
errors.
3 to >2.0 pts
Fair
Contains several
(3-4) grammar,
spelling, and
punctuation
errors.
2 to >0 pts
Poor
Contains many (≥ 5)
grammar, spelling,
and punctuation
errors that interfere
with the reader’s
understanding.
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
22. 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.
Read rating descriptions to see the grading standards!
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
23. 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
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.
24. 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.
25. 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
26. 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
27. 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
28. 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)
