NRNPPRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Eva.docx

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
Page 1 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
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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
Required Media
· PsychScene Hub. (2017, April 24).
Movement disorders with antipsychotic
medication Links to an external site.- Conversations with Dr.
Stephen Stahl [Video]. YouTube.
https://www.youtube.com/watch?v=ipW5AcbFzzE
· Vallejo, E. (2020).
Realistic schizophrenia simulation Links to an external
site. [Video]. YouTube.
https://www.youtube.com/watch?v=63lHuGMbscU
[MUSIC PLAYING] DR. MOORE: Good afternoon. I'm Dr.
Moore. Want to thank you for coming
in for your appointment today. I'm going to be asking you some
questions about your history and some symptoms. And to get
started,
I just want to ensure I have the right
patient and chart. So can you tell me your
name and your date of birth? SHERMAN TREMAINE:
I'm Sherman Tremaine, and Tremaine is my game game. My
birthday is November 3, 1968. DR. MOORE: Great. And can
you tell
me today's date? Like the day of the week,

and where we are today? SHERMAN TREMAINE: Use any
recent
date, and any location is OK. DR. MOORE: OK, Sherman. What
about do you know
what month this is? SHERMAN TREMAINE: It's March 18. DR.
MOORE: And the
day of the week? SHERMAN TREMAINE: Oh, it's a
Wednesday or maybe a Thursday. DR. MOORE: OK. And where
are we today? SHERMAN TREMAINE:
I believe we're in your office, Dr. Moore. DR. MOORE: OK,
great. So tell me a little bit about
what brings you in today. What brings you here? SHERMAN
TREMAINE: Well,
my sister made me come in. I was living with my
mom, and she died. I was living, and not bothering
anyone, and those people-- those people, they just
won't leave me alone. DR. MOORE: What people? SHERMAN
TREMAINE: The ones
outside my window watching. They watch me. I can hear them,
and
I see their shadows. They think I don't
see them, but I do. The government sent
them to watch me, so my taxes are high,
so high in the sky. Do you see that bird? DR. MOORE:
Sherman,
how long have you saw or heard these people? SHERMAN
TREMAINE: Oh, for weeks,
weeks and weeks and weeks. Hear that-- hear that
heavy metal music? They want you to think
it's weak, but it's heavy. DR. MOORE: No, Sherman. I don't see
any birds
or hear any music. Do you sleep well, Sherman? SHERMAN
TREMAINE: I try to
but the voices are loud. They keep me up
for days and days. I try to watch TV, but they
watch me through the screen, and they come in

and poison my food. I tricked them though. I tricked them. I
locked everything
up in the fridge. They aren't getting in there. Can I smoke? DR.
MOORE: No, Sherman. There is no smoking here. How much do
you usually smoke? SHERMAN TREMAINE: Well,
I smoke all day, all day. Three packs a day. DR. MOORE: Three
packs a day. OK. What about alcohol? When was your last
drink? SHERMAN TREMAINE: Oh, yesterday. My sister buys
me a 12-pack,
and tells me to make it last until next week's grocery run. I
don't go to the grocery store. They play too loud of
the heavy metal music. They also follow me there. DR.
MOORE: What about marijuana? SHERMAN TREMAINE: Yes,
but not since my mom died three years ago. DR. MOORE: Use
any cocaine? SHERMAN TREMAINE: No,
no, no, no, no, no, no. No drugs ever, clever, ever. DR.
MOORE: What about
any blackouts or seizures or see or hear things
from drugs or alcohol? SHERMAN TREMAINE: No, no, never
a clever [INAUDIBLE] ever. DR. MOORE: What about
any DUIs or legal issues from drugs or alcohol? SHERMAN
TREMAINE:
Never clever's ever. DR. MOORE: OK. What about any
medication
for your mental health? Have you tried those before, and
what was your reaction to them? SHERMAN TREMAINE: I
hate
Haldol and Thorazine. No, no, I'm not
going to take it. Risperidone gave me boobs. No, I'm not going
to take it. Seroquel, that is OK. But they're all poison,
nope, not going to take it. DR. MOORE: OK. So tell me, any
blood relatives have any mental health or
substance abuse issues? SHERMAN TREMAINE:
They say that my dad was crazy with
paranoid schizophrenia. He did in the old
state hospital. They gave him his beer there. Can you believe

that? Not like them today. My mom had anxiety. DR. MOORE:
Did any blood
relatives commit suicide? SHERMAN TREMAINE:
Oh, no demons there. No, no. DR. MOORE: What about you?
Have you ever done anything
like cut yourself, or had any thoughts about killing
yourself or anyone else? SHERMAN TREMAINE:
I already told you. No demons there. Have been in the hospital
three
times though when I was 20. DR. MOORE: OK. What about any
medical issues? Do you have any
medical problems? SHERMAN TREMAINE: Ooh, I
take metformin for diabetes. Had or I have a fatty
liver, they say, but they never saw it. So I don't know unless
the aliens told them. DR. MOORE: OK. So who raised you?
SHERMAN TREMAINE: My
mom and my sister. DR. MOORE: And who
do you live with now? SHERMAN TREMAINE:
Myself, but my sister's plotting with the
government to change that. They tapped my phone. DR.
MOORE: OK. Have you ever been married? Are you single,
widowed, or divorced? SHERMAN TREMAINE: I've
never been married. DR. MOORE: Do you
have any children? SHERMAN TREMAINE: No. DR. MOORE:
OK. What is your highest
level of education? SHERMAN TREMAINE: I
went to the 10th grade. DR. MOORE: And what do
you like to do for fun? SHERMAN TREMAINE: I don't work,
so smoking and drinking pop. DR. MOORE: OK. Have you ever
been arrested or
convicted for anything legally? SHERMAN TREMAINE: No,
but
they have told me they would. They have told me they would
if I didn't stop calling 911 about the people outside. DR.
MOORE: OK. What about any kind of trauma
as a child or an adult? Like physical, sexual,

emotional abuse. SHERMAN TREMAINE: My dad was
rough on us until he died. DR. MOORE: OK. [MUSIC
PLAYING] So thank you for answering
those questions for me. Now, let's talk about
how I can best help you. [MUSIC PLAYING]
Case study
[MUSIC PLAYING] DR. MOORE: Good afternoon. I'm Dr.
Moore. Want to thank you for coming
in for your appointment today. I'm going to be asking you some
questions about your history and some symptoms. And to get
started,
I just want to ensure I have the right
patient and chart. So can you tell me your
name and your date of birth? SHERMAN TREMAINE:
I'm Sherman Tremaine, and Tremaine is my game game. My
birthday is November 3, 1968. DR. MOORE: Great. And can
you tell
me today's date? Like the day of the week,
and where we are today? SHERMAN TREMAINE: Use any
recent
date, and any location is OK. DR. MOORE: OK, Sherman. What
about do you know
what month this is? SHERMAN TREMAINE: It's March 18. DR.
MOORE: And the
day of the week? SHERMAN TREMAINE: Oh, it's a
Wednesday or maybe a Thursday. DR. MOORE: OK. And where
are we today? SHERMAN TREMAINE:
I believe we're in your office, Dr. Moore. DR. MOORE: OK,
great. So tell me a little bit about
what brings you in today. What brings you here? SHERMAN
TREMAINE: Well,
my sister made me come in. I was living with my
mom, and she died. I was living, and not bothering
anyone, and those people-- those people, they just
won't leave me alone. DR. MOORE: What people? SHERMAN

TREMAINE: The ones
outside my window watching. They watch me. I can hear them,
and
I see their shadows. They think I don't
see them, but I do. The government sent
them to watch me, so my taxes are high,
so high in the sky. Do you see that bird? DR. MOORE:
Sherman,
how long have you saw or heard these people? SHERMAN
TREMAINE: Oh, for weeks,
weeks and weeks and weeks. Hear that-- hear that
heavy metal music? They want you to think
it's weak, but it's heavy. DR. MOORE: No, Sherman. I don't see
any birds
or hear any music. Do you sleep well, Sherman? SHERMAN
TREMAINE: I try to
but the voices are loud. They keep me up
for days and days. I try to watch TV, but they
watch me through the screen, and they come in
and poison my food. I tricked them though. I tricked them. I
locked everything
up in the fridge. They aren't getting in there. Can I smoke? DR.
MOORE: No, Sherman. There is no smoking here. How much do
you usually smoke? SHERMAN TREMAINE: Well,
I smoke all day, all day. Three packs a day. DR. MOORE: Three
packs a day. OK. What about alcohol? When was your last
drink? SHERMAN TREMAINE: Oh, yesterday. My sister buys
me a 12-pack,
and tells me to make it last until next week's grocery run. I
don't go to the grocery store. They play too loud of
the heavy metal music. They also follow me there. DR.
MOORE: What about marijuana? SHERMAN TREMAINE: Yes,
but not since my mom died three years ago. DR. MOORE: Use
any cocaine? SHERMAN TREMAINE: No,
no, no, no, no, no, no. No drugs ever, clever, ever. DR.
MOORE: What about

any blackouts or seizures or see or hear things
from drugs or alcohol? SHERMAN TREMAINE: No, no, never
a clever [INAUDIBLE] ever. DR. MOORE: What about
any DUIs or legal issues from drugs or alcohol? SHERMAN
TREMAINE:
Never clever's ever. DR. MOORE: OK. What about any
medication
for your mental health? Have you tried those before, and
what was your reaction to them? SHERMAN TREMAINE: I
hate
Haldol and Thorazine. No, no, I'm not
going to take it. Risperidone gave me boobs. No, I'm not going
to take it. Seroquel, that is OK. But they're all poison,
nope, not going to take it. DR. MOORE: OK. So tell me, any
blood relatives have any mental health or
substance abuse issues? SHERMAN TREMAINE:
They say that my dad was crazy with
paranoid schizophrenia. He did in the old
state hospital. They gave him his beer there. Can you believe
that? Not like them today. My mom had anxiety. DR. MOORE:
Did any blood
relatives commit suicide? SHERMAN TREMAINE:
Oh, no demons there. No, no. DR. MOORE: What about you?
Have you ever done anything
like cut yourself, or had any thoughts about killing
yourself or anyone else? SHERMAN TREMAINE:
I already told you. No demons there. Have been in the hospital
three
times though when I was 20. DR. MOORE: OK. What about any
medical issues? Do you have any
medical problems? SHERMAN TREMAINE: Ooh, I
take metformin for diabetes. Had or I have a fatty
liver, they say, but they never saw it. So I don't know unless
the aliens told them. DR. MOORE: OK. So who raised you?
SHERMAN TREMAINE: My
mom and my sister. DR. MOORE: And who

do you live with now? SHERMAN TREMAINE:
Myself, but my sister's plotting with the
government to change that. They tapped my phone. DR.
MOORE: OK. Have you ever been married? Are you single,
widowed, or divorced? SHERMAN TREMAINE: I've
never been married. DR. MOORE: Do you
have any children? SHERMAN TREMAINE: No. DR. MOORE:
OK. What is your highest
level of education? SHERMAN TREMAINE: I
went to the 10th grade. DR. MOORE: And what do
you like to do for fun? SHERMAN TREMAINE: I don't work,
so smoking and drinking pop. DR. MOORE: OK. Have you ever
been arrested or
convicted for anything legally? SHERMAN TREMAINE: No,
but
they have told me they would. They have told me they would
if I didn't stop calling 911 about the people outside. DR.
MOORE: OK. What about any kind of trauma
as a child or an adult? Like physical, sexual,
emotional abuse. SHERMAN TREMAINE: My dad was
rough on us until he died. DR. MOORE: OK. [MUSIC
PLAYING] So thank you for answering
those questions for me. Now, let's talk about
how I can best help you. [MUSIC PLAYING]
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.
· Review the video,
Case Study: Sherman Tremaine. You will use this case
as the basis of this Assignment. In this video, a Walden faculty
member is assessing a mock patient. The patient will be
represented onscreen as an avatar.
· Consider what history would be necessary to collect from this
patient.
· Consider what interview questions you would need to ask this
patient.
THE ASSIGNMENT
Develop a focused SOAP note, including your differential
diagnosis and critical-thinking process to formulate a primary
diagnosis. Incorporate the following into your responses in the
template:
· Subjective: What details did the patient provide regarding
their chief complaint and symptomology to derive your
differential diagnosis? What is the duration and severity of their
symptoms? How are their symptoms impacting their functioning
in life?
· Objective: What observations did you make during the
psychiatric assessment?
· Assessment: Discuss the patient’s mental status examination

results. What were your differential diagnoses? Provide a
minimum of three possible diagnoses with supporting evidence,
and list them in order from highest priority to lowest priority.
Compare the
DSM-5-TR diagnostic criteria for each differential
diagnosis and explain what
DSM-5-TR criteria rules out the differential diagnosis
to find an accurate diagnosis. Explain the critical-thinking
process that led you to the primary diagnosis you selected.
Include pertinent positives and pertinent negatives for the
specific patient case.
· Plan: What is your plan for psychotherapy? What is your plan
for treatment and management, including alternative therapies?
Include pharmacologic and nonpharmacologic treatments,
alternative therapies, and follow-up parameters, as well as a
rationale for this treatment and management plan. Also
incorporate one health promotion activity and one patient
education strategy.
· Reflection notes: What would you do differently with this
patient if you could conduct the session again? Discuss what
your next intervention would be if you were able to follow up
with this patient. Also include in your reflection a discussion
related to legal/ethical considerations (demonstrate critical
thinking beyond confidentiality and consent for treatment!),
health promotion, and disease prevention, taking into
consideration patient factors (such as age, ethnic group, etc.),
PMH, and other risk factors (e.g., socioeconomic, cultural
background, etc.).
· Provide at least three evidence-based, peer-reviewed journal
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).

NRNPPRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Eva.docx

NRNPPRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Eva.docx

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