Comprehensive soap note – Mood disorder please see the attached instruction.
Due Dec 22 by 11:59pm
Points 100
Submitting a text entry box or a file upload
Attempts 0
Allowed Attempts 2
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It is important for the PMHNP to have a comprehensive understanding of mood disorders in order to
assess and accurately formulate a diagnosis and treatment plan for patients presenting with these
disorders. Mood disorders may be diagnosed when a patient’s emotional state meets the diagnostic
criteria for severity, functional impact, and length of time. Those with a mood disorder may find that their
emotions interfere with work, relationships, or other parts of their lives that impact daily functioning. Mood
disorders may also lead to substance abuse or suicidal thoughts or behaviors, and although they are not
likely to go away on their own, they can be managed with an effective treatment plan and understanding
of how to manage symptoms.
In this Assignment you will assess, diagnose, and devise a treatment plan for a patient in a case study
who is presenting with a mood disorder.
ASSESSING, DIAGNOSING, AND TREATING
ADULTS WITH MOOD DISORDERS
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RESOURCES
12/14/24, 10:24 PM Week 4: Assignment
1/7
Review this week’s Learning Resources. Consider the insights they provide about assessing,
diagnosing, and treating mood disorders.
Review the Focused SOAP Note template, which you will use to complete this Assignment. There is
also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
Review the video, Case Study: Petunia Park. You will use this case as the basis of this Assignment.
In this video, a Walden faculty member is assessing a mock patient. The patient will be represented
onscreen as an avatar.
Consider what history would be necessary to collect from this patient.
Consider what interview questions you would need to ask this patient.
Consider patient diagnostics missing from the video:
Provider Review outside of interview:
Temp 98.2 Pulse 90 Respiration 18 B/P 138/88
Laboratory Data Available: Urine drug and alcohol screen negative. CBC within normal ranges,
CMP within normal ranges. Lipid panel within normal ranges. Prolactin Level 8; TSH 6.3 (H)
Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to
formulate a primary diagnosis. Incorporate the following into your responses in the template:
Subjective: What details did the patient provide regarding their chief complaint and symptomatology
to derive your differential diagnosis? What is the duration and severity of their symptoms? How are
their symptoms impacting their functioning in life?
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES (
TO PREPARE
THE ASSIGNMENT
12/14/24, 10:24 PM Week 4: Assignment
2/7
NRNP_6665_Week4_Assignment_Rubric
Objective: What observations did you make during the psychiatric assessment?
Assessment: Discuss the patient’s mental status examination results. What were your differential
diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order
from highest to lowest priority. Compare the DSM-5-TR 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.
Plan: What is your plan for psychotherapy? What is your plan for treatment and management,
including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative
therapies, and follow-up parameters as well as a rationale for this treatment and management
plan. Also incorporate one health promotion activity and one patient education strategy.
Reflection notes: Reflect on this case. Discuss what you learned and what you might do differently.
Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical
thinking beyond confidentiality and consent for treatment!), social determinates of health, health
promotion, and disease prevention that takes into consideration patient factors (such as age, ethnic
group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
Submit your Focused SOAP Note.
Before submitting your final assignment, you can check your draft for authenticity. To check your
draft, access the Turnitin Drafts from the Start Here area.
1. To submit your completed assignment, save your Assignment as WK1Assgn+last
name+first initial.
2. Then, click on Start Assignment near the top of the page.
3. Next, click on Upload File and select Submit Assignment for review.
BY DAY 7 OF WEEK 4
SUBMISSION INFORMATION
12/14/24, 10:24 PM Week 4: Assignment
3/7
Criteria Ratings Pts
15 pts
15 pts
20 pts
Create
documentation in the
Focused SOAP Note
Template about the
patient in the case
study. 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
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
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
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
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.
In the Objective
section, provide:•
Review of Systems
(ROS)
documentation and
relate if 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
Excellent
The response
thoroughly and
accurately
documents the
patient’s ROS for
pertinent systems.
Diagnostic tests
and their results
are thoroughly
and accurately
documented.
13 to >11.0 pts
Good
The response
accurately
documents the
patient’s ROS for
pertinent
systems.
Diagnostic tests
and their results
are accurately
documented.
11 to >10.0 pts
Fair
Documentation of
the patient’s ROS
is somewhat
vague or contains
minor
innacuracies.
Diagnostic tests
and their results
are documented
but contain minor
inaccuracies.
10 to >0 pts
Poor
The response
provides
incomplete or
inaccurate
documentation of
the patient’s
ROS. Systems
may have been
unnecessarily
reviewed. Or the
objective
documentation is
missing.
In the Assessment
section, provide:•
Results of the mental
20 to >17.0 pts
Excellent
17 to >15.0 pts
Good
15 to >13.0 pts
Fair
13 to >0 pts
Poor
12/14/24, 10:24 PM Week 4: Assignment
4/7
Criteria Ratings Pts
25 pts
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.
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.
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.
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.
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.
In 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
25 to >22.0 pts
Excellent
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
22 to >19.0 pts
Good
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
19 to >17.0 pts
Fair
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,
17 to >0 pts
Poor
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,
12/14/24, 10:24 PM Week 4: Assignment
5/7
Criteria Ratings Pts
5 pts
activity and one
patient education
strategy.
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.
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.
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.
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.
• Reflect on this
case. Discuss what
you learned and
what you might do
differently. Also
include in your
reflection a
discussion related to
legal/ethical
considerations
(demonstrate critical
thinking beyond
confidentiality and
consent for
treatment!), social
determinates of
health, health
promotion, and
disease prevention
that takes into
consideration patient
factors (such as age,
ethnic group, etc.),
PMH, and other risk
factors (e.g.,
socioeconomic,
5 to >4.0 pts
Excellent
Reflections are
thorough,
thoughtful, and
demonstrate critical
thinking.
4 to >3.5 pts
Good
Reflections
demonstrate
critical thinking.
3.5 to >3.0 pts
Fair
Reflections are
somewhat general or
do not demonstrate
critical thinking.
3 to >0 pts
Poor
Reflections are
incomplete,
inaccurate, or
missing.
12/14/24, 10:24 PM Week 4: Assignment
6/7
Total Points: 100
Criteria Ratings Pts
10 pts
5 pts
5 pts
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).
10 to >8.0 pts
Excellent
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
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
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
Two or fewer
resources are
provided to
support the
assessment
and diagnosis
decisions. The
resources may
not be current
or evidence
based.
Written Expression
and Formatting – The
paper follows correct
APA format for
parenthetical/in-text
citations and
reference list.
5 to >4.0 pts
Excellent
Uses correct
APA format with
no errors
4 to >3.5 pts
Good
Contains a few
(one or two) APA
format errors
3.5 to >3.0 pts
Fair
Contains several
(three or four) APA
format errors
3 to >0 pts
Poor
Contains many
(five or more)
APA format
errors
Written Expression
and Formatting –
English Writing
Standards: Correct
grammar, mechanics,
and punctuation
5 to >4.0 pts
Excellent
Uses correct
grammar,
spelling, and
punctuation with
no errors
4 to >3.5 pts
Good
Contains a few
(one or two)
grammar,
spelling, and
punctuation
errors
3.5 to >3.0 pts
Fair
Contains several
(three or four)
grammar, spelling,
and punctuation
errors
3 to >0 pts
Poor
Contains many (five
or more) grammar,
spelling, and
punctuation errors
that interfere with the
reader’s
understanding
12/14/24, 10:24 PM Week 4: Assignment
7/7
