NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template Week (enter week #): (Enter assignment title) Student Name College of Nursing-PMHNP, Walden University NRNP 6665: PMHNP Care Across the Lifespan I Faculty Name Assignment Due Date Subjective: CC (chief complaint): HPI: Substance Current Use: Medical History: · Current Medications: · Allergies: · Reproductive Hx: ROS: · GENERAL: · HEENT: · SKIN: · CARDIOVASCULAR: · RESPIRATORY: · GASTROINTESTINAL: · GENITOURINARY: · NEUROLOGICAL: · MUSCULOSKELETAL: · HEMATOLOGIC: · LYMPHATICS: · ENDOCRINOLOGIC: Objective: Diagnostic results: Assessment: Mental Status Examination: Diagnostic Impression: Reflections: Case Formulation and Treatment Plan: References © 2021 Walden University Page 1 of 3 Assignment 2: Focused SOAP Note and Patient Case Presentation For this Assignment, you will document information about a patient that you examined during the last 3 weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient. Be sure to incorporate any feedback you received on your Week 3 and Week 7 case presentations into this final presentation for the course. To Prepare Select a child or adolescent patient that you examined during the last 3 weeks who presented with a disorder for which you have not already created a Focused SOAP Note in Weeks 3 or 7. (For instance, if you selected a patient with anorexia nervosa in Week 7, you must choose a patient with another type of disorder for this week.) Create a Focused SOAP Note on this patient using the template provided in the Learning Resources.. Please Note: When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor. You must submit your SOAP note using SafeAssign. Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy. Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record. Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning. The Assignment Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management. Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value. Specifically address the following for the patient, using your SOAP note as a guide: S.

1. NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP
Psychiatric Evaluation Template
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6665: PMHNP Care Across the Lifespan I
Faculty Name
Assignment Due Date
Subjective:
CC (chief complaint):
HPI:
Substance Current Use:
Medical History:
·
Current Medications:
·
Allergies:
·
Reproductive Hx:
ROS:
· GENERAL:
· HEENT:

2. · 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
Assignment 2: Focused SOAP Note and Patient Case
Presentation
For this Assignment, you will document information about a
patient that you examined during the last 3 weeks, using the
Focused SOAP Note Template provided. You will then use this

3. note to develop and record a case presentation for this patient.
Be sure to incorporate any feedback you received on your Week
3 and Week 7 case presentations into this final presentation for
the course.
To Prepare
Select a child or adolescent patient that you examined during
the last 3 weeks who presented with a disorder for which you
have not already created a Focused SOAP Note in Weeks 3 or 7.
(For instance, if you selected a patient with anorexia nervosa in
Week 7, you must choose a patient with another type of disorder
for this week.)
Create a Focused SOAP Note on this patient using the template
provided in the Learning Resources..
Please Note:
When you submit your note, you should include the complete
focused SOAP note as a Word document and PDF/images of
each page that is initialed and signed by your Preceptor.
You must submit your SOAP note using SafeAssign. Note: If
both files are not received by the due date, faculty will deduct
points per the Walden Grading Policy.
Then, based on your SOAP note of this patient, develop a video
case study presentation. Take time to practice your presentation
before you record.
Include at least five scholarly resources to support your
assessment, diagnosis, and treatment planning.
The Assignment
Present the full complex case study. Include chief complaint;
history of present illness; any pertinent past psychiatric,
substance use, medical, social, family history; most recent
mental status exam; current psychiatric diagnosis including
differentials that were ruled out; and plan for treatment and
management.
Report normal diagnostic results as the name of the test and
“normal” (rather than specific value). Abnormal results should
be reported as a specific value.

4. Specifically address the following for the patient, using your
SOAP note as a guide:
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 their mental status examination results.
What were your differential diagnoses? Provide a minimum of
three possible diagnoses and why you chose them. List them
from highest priority to lowest priority. What was your primary
diagnosis, and why? Describe how your primary diagnosis
aligns with DSM-5 diagnostic criteria and supported by the
patient’s symptoms.
Plan: In your video, describe your treatment plan using clinical
practice guidelines supported by evidence-based practice.
Include a discussion on your chosen FDA-approved
psychopharmacologic agents and include alternative treatments
available and supported by valid research. All treatment choices
must have a discussion of your rationale for the choice
supported by valid research. What were your follow-up plan and
parameters? What referrals would you make or recommend as a
result of this treatment session?
In your written plan include all the above as well as include one
social determinant of health according to the HealthyPeople
2030 (you will need to research) as applied to this case in the
realm of psychiatry and mental health. As a future advanced
provider, what are one health promotion activity and one patient
education consideration for this patient for improving health
disparities and inequities in the realm of psychiatry and mental
health? Demonstrate your critical thinking.
Reflection notes: What would you do differently with this
patient if you could conduct the session over? If you are able to
follow up with your patient, explain whether these interventions
were successful and why or why not. If you were not able to

5. conduct a follow up, discuss what your next intervention would
be.
Case study presentation
Cc Psych eval
HISTORY: Aiden is a 5-year-old boy. This evaluation was
requested because "the primary care
doctor want us to have an evaluation for ADHD". Mother report
that patient has "been having a lot
of issues at school. He walks around the class, hit, push, shove
other students, interupt others,
unable to wait his turn or complete his work. he cannot work in
group setting. he even pushed
someone yesterday at school and he was send home early. the
other person has injury. the teacher
had to put his chair at her table just to prevent distraction but it
has not helped". mother report that
patient's classroom teacher and herself completed the vanderbilt
form that was provided by pcp.
Information Received From: patient and mother
Behavior Described In:
Aiden exhibits hyperactive and attentional difficulties both in
school and at home.
ADHD Symptoms:
Aiden exhibits symptoms of inattention. Careless mistakes are
typical. He reports difficulty
sustaining attention. He does not seem to listen when spoken to
directly. He often needs directions
repeated. Projects or tasks are often not completed. He needs
extra time to complete his
assignments. Aiden reports being disorganized. He finds it
difficult to keep his book bag or school
locket organized. Tasks requiring sustained mental effort are
difficult for Aiden to accomplish. His
mind easily wanders or becomes distracted. Aiden is easily
distracted by other people. by the

6. radio. by noises. He describes being inattentive. He often needs
directions repeated. He has a
short attention span. Aiden needs supervision or frequent
redirection.
Aiden exhibits signs of hyperactivity. He exhibits restlessness
or fidgety behavior. This
behavior is evident during school hours. He has a tendency to
frequently leave his seat. Playing
quietly is difficult for Aiden . He is always “on the go” , and is
unable to be still for an extended
period of time. He is easily bored and changes activities
frequently. Aiden 's excessive movement
has been noted. He is fidgety or squirms when required to sit
still for a period of time. He
frequently jumps or climbs.
Aiden exhibits signs of impulsive behavior. He frequently
interrupts others. He has
problems waiting for his turn. He often acts in a reckless
manner (has sustain multiple injury from
jumping, hiting his head etc) .
Severity:
The attentional difficulties described cause moderate
impairment in Aiden 's functioning.
Respiratory: hx of asthma
Review of all other systems reviewed were negative. No Test
Results were received.
The Vanderbilt Assessment Scale:
A questionnaire that scans for symptoms of ADHD, ODD,
Conduct Disorder, and
anxiety/depression in children. Aiden 's assessment results are
as follows:
*Parent's Assessment:
Scoring indicates the presence of ADHD, combined
Hyperactive/Inattentive type.
*Teacher's Assessment: Scoring indicates the presence of
ADHD, combined

7. Hyperactive/Inattentive type.
PAST PSYCHIATRIC HISTORY:
Psychiatric Hospitalization:
Aiden has never been psychiatrically hospitalized.
Outpatient Treatment:
Has never received outpatient mental health treatment.
Suicidal/Self Injurious:
Aiden has no history of suicidal or self injurious behavior.
Psychotropic Medication History:
Psychotropic medications have never been prescribed for Aiden
EXAM: Aiden presents as happy, distracted, well groomed,
normal weight child. He exhibits
speech that is normal in rate, volume, and articulation and is
coherent and spontaneous. Language
skills are appropriate for age.. Affect is appropriate, full range,
and congruent with mood.
Associations are intact and logical. There are no apparent signs
of hallucinations, delusions,
bizarre behaviors, or other indicators of psychotic process.
cognitive functioning appropriate for
age. Insight into problems appears fair. Judgment appears to be
poor. He is easily distracted. A
short attention span is evident. There is physical hyperactivity.
Aiden is fidgety. Aiden is restless
during assessment. Aiden was intrusive during the examination.
Supine blood pressure is 98 / 52.
Supine pulse rate is 69. Weight is 65 lbs. (29.5 Kg).
TREATMENT PLAN she was
Hesitant due to cultural background, educational material on
medication and diagnosis given to
mother who was encouraged to call and make appointment when
she is ready to begin treatment.