Our Services

Get 15% Discount on your First Order

[rank_math_breadcrumb]

soap Note

PMHNP Problem-Focused SOAP Note

(Use this template for this Assignment)

Demographic Data

· Patient age and Patient’s gender identity

· MUST BE HIPAA compliant.


Subjective

Chief Complaint (CC):

· Place the patient’s CC complaint in Quotes

History of Present Illness (HPI):

·
Reason for an appointment today.

· The events that led to hospitalization or clinic visits today.

· Include symptoms, relieving factors, and past compliance or non-compliance with medications

· Any adverse effects from past medication use

· Sleep patterns – number of hours of sleep per day, early wakefulness, not being able to initiate sleep, not able to stay asleep, etc.

· Suicide or homicide thoughts present

· Any self-care or Activity of Daily Living (ADL) such as eating, drinking liquids, self-care deficits or issues noted?

· Presence/description of psychosis (if psychosis, command or non-command)

Past Psychiatric History (PSH):

· Past psychiatric diagnoses

· Past hospitalizations

· Past psychiatric medications use

· Any non-compliance issues in the past?

· Any meds that didn’t work for this patient?

Family History of Psychiatric Conditions or Diagnoses:

· Mother/father, siblings, grandparents, or
direct relatives

Social History: 

· Include nutrition, exercise, substance use (details of use), sexual history/preference, occupation (type), highest school achievement, financial problems, legal issues, children, history of personal abuse (including sexual, emotional, or physical).

Allergies:

· to medications, foods, chemicals, and other.

Review of Systems (ROS) (Physical Complaints):

· Any physical complaints by body system? (Respiratory, Cardiac, Renal, etc.)


Objective

Mental Status Exam:

· This is not physical exam.

· Mini-Mental Status Exam (MMSE) – Full exam


Assessment (Diagnosis)

Differentials

· Two (
2) differential diagnoses with ICD-10 codes.

· Must include rationale using DSM-5 Criteria (
Required)

· Why didn’t you pick these as a major diagnosis?

Working Diagnosis

· Final or working diagnosis (
1), with ICD-10 code.

· Must include rationale using DSM-5 criteria required – Which symptoms/signs in the DSM-5 the patient matches mostly)


Plan

Treatment Plan (Tx Plan):

· Pharmacologic: Include full information for each medication(s) prescribed

· Refill Provided: Include full information for each medication(s) refilled

Patient Education:

· including specific medication teaching points

· Was risk versus benefit of current treatment plan addressed for meds or treatment

· Risk versus benefit of non-FDA approved for working diagnosis – Off-label use of medication education to patient addressed?

Prognosis:

· Make Decision for prognosis: Good, Fair, Poor

· Provide brief statement lending support

for
or

against
the decided prognosis.

Therapy Recommendations:

· Type(s) of therapy recommended.

Referral/Follow-up:

· Did you recommend follow-up with Psychiatrist, PCP, or other specialist or healthcare professionals?

· When is the subsequent follow-up?

· Include rationale for the F/U recommendation or referral.

Reference(s):

· Include American Psychological Association (APA) formatted references.

· Include a reference from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) or the accompanying Desk Reference of Diagnostic Criteria from DSM-5.

· Minimum 2 references are required.

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

Nursing

see attachment For this assessment, you will propose a hypothetical health promotion plan addressing a particular health concern or health need affecting a fictitious individual or group living in the community. The hypothetical individual or group of your choice must be living in the community, not in a hospital, assistant

Nursing Homework

help with assignment To Prepare: · Identify two to three scholarly resources, in addition to this Module’s readings, that evaluate the impact of leadership behaviors in creating healthy work environments. · Reflect on the leadership behaviors presented in the three resources that you selected for review. · Reflect on your

J

Mrs. Lisa Horowitz is a 35 year-old Orthodox Jewish woman, who is married for 10 years, and has six (6) children all under 15 years-of-age.  Today, she seeks care from her OB/GYN for abnormal uterine bleeding.  After a thorough evaluation, diagnostics and imaging, her results confirm a uterine mass.  Further

week 5

See attached for instructions  Post an explanation of at least two strategies for including academic activities and accomplishments into your professional development goals. Then, explain how those goals may align with the University’s emphasis on social change. Be specific and provide examples. Plz provide 350 words Plz provide references

NUR 630

NUR 630 Weekly Discussion Submission Instructions: • Your initial post should be at least 500 words or more, 1. Introduction to Child Psychiatry After studying Module 1: Lecture Materials & Resources, address the following in a well-written discussion post: • Should we be “diagnosing” children with psychological disorders?  Use current US scholarly

final project breast cancer survivors

Your final paper will encompass all assignments you have completed thus far. At this point, you will have submitted each section individually and a comprehensive rough draft. You have received extensive feedback. An attempt to incorporate all previous assignment feedback should be evident. 
 The paper should be between 20

Nursing HCAD ASSIGNMENT 2

 Grading will focus on content development, depth of analysis and professionalism of delivery. Your final deliverable will be a presentation of no more than 10 minutes in length, developed in an MS PowerPoint slide deck suitable for presentation to the Board of Directors or a C-Suite executive team. 

narrated power point

A narrated PowerPoint on Diverticulitis. PLEASE include narration on the PowerPoint. Name of Disease: Definition Diverticulitis Epidemiology risk factor clinical picture narration Characteristics of diverticulitis with pictures( ABCD ) REFERENCES :

DNP

Choose at least 3 of the golden rules of leadership discussed during this module, and explain the best way you can implement them in your workplace with samples. Remember to review the  academic expectations for your submission. Submission Instructions: · Your initial post should be at least 450 words, formatted, and

DNP

D.N.P. Leadership Role in the Conflict Solution and Crisis Management Instructions: Think about a crisis or conflict in your work area, and develop an essay of a minimum of three pages explaining how, as a D.N.P. Leadership Role, you can use the strategies for conflict solution and crisis management to

Biostadistic

Using the reading covered in this module review the scenarios below. For each method, determine if a probability sampling or non probability sampling method is used. For each question, determine if this an effective way to determine patient satisfaction. Why or why not? 1. The CEO of a regional hospital

Biostadistic

Using the AGMU virtual library select one research paper on a topic of interest to you that reports quantitative research. Summarize the research by answering the following questions: 1. Identify where the steps in the scientific method lie within the paper. 2. Decide whether or not the paper follows the

Action Plan Review Presentation at the Clinical Site Peer Review

Action Plan Review Presentation at the Clinical Site Peer Review You will schedule a meeting with your Faculty Member, preceptor and stakeholders to review your action plan for your DNP Project during weeks 8, 9, or 10. You will also complete your practicum meeting with the preceptor at that time.

Nursing homework question 1017

3. Personal Statement or Philosophy of Practice  · 1–2 pages outlining your values, goals, and vision as an NP. 12. Reflection  · 1–2 page reflection on your NP journey and future goals

nursing

1) Read a selection of your colleagues’ posts. Respond to at least two of your colleagues on 2 different days by supporting or expanding on the ideas identified by your colleagues or sharing additional perspectives on the issue described by your colleagues. 2) Post substantive responses to at least two colleagues on two different days

ASSESSMENT 4_6026

What are some of your personal goals for personal, professional, and leadership development that you will achieve in the practicum experience? During my practicum, my personal goals include strengthening my self-awareness and emotional intelligence to better navigate professional challenges and interpersonal dynamics. I also aim to develop my adaptability and

Care Coordination Presentation to Colleagues

Your preceptor has been observing your effectiveness as a care coordinator and recognizes the importance of educating other staff nurses in care coordination. Consequently, she has asked you to develop a presentation for your colleagues on care coordination basics. By providing them with basic information about the care coordination process,

Final Care Coordination Strategy

You are encouraged to complete the Vila Health: Cultural Competence activity prior to completing this assessment. Completing course activities before submitting your first attempt has been shown to make the difference between basic and proficient assessment. In this assessment, you will evaluate the preliminary care coordination infographic you developed in