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Nursing homework help

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.

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