Clinical: SOAP Note

Instructions

Every other week students will choose one patient encounter to submit a Follow-up SOAP note for review. 

Follow the rubric to develop your SOAP notes for this term. 

The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.(SOAP Note on Psychiatric Evaluations for Nursing Students)

Rubric

NU674 Unit 12 Assignment – Clinical: SOAP Note

NU674 Unit 12 Assignment – Clinical: SOAP Note

Criteria

Ratings

Pts

This criterion is linked to a Learning OutcomeSubjective Information

3 pts

Level 5

Complete and concise summary of pertinent information.

2 pts

Level 3

Well organized; partial but accurate summary of pertinent information (>80%).

1 pts

Level 1

Poorly organized and/or limited summary of pertinent information (50%-80%); information other than “S” provided.

0 pts

Level 0

Less than 50% of pertinent information is addressed; or is grossly incomplete and/or inaccurate.

3 pts

This criterion is linked to a Learning OutcomeObjective Information

3 pts

Level 5

Complete and concise summary of pertinent information.

2 pts

Level 3

Partial but accurate summary of pertinent information (>80%).

1 pts

Level 1

Poorly organized and/or limited summary of pertinent information (50%-80%); information other than “O” provided.

0 pts

Level 0

Less than 50% of pertinent information is addressed; or is grossly incomplete and/or inaccurate.

3 pts

This criterion is linked to a Learning OutcomeAssessment: Problem Identification and Prioritization

3 pts

Level 5

Complete problem list generated and rationally prioritized; no extraneous information or issues listed.

2 pts

Level 3

Most problems are identified and rationally prioritized, including the “main” problem for the case (>80%).

1 pts

Level 1

Some problems are identified (50%-80%); incomplete or inappropriate problem prioritization; includes nonexistent problems or extraneous information included.(SOAP Note on Psychiatric Evaluations for Nursing Students)

0 pts

Level 0

Less than 50% of problems are listed; or main problem missed; or problems not prioritized and/or identified nonexistent problems.(SOAP Note on Psychiatric Evaluations for Nursing Students)

3 pts

This criterion is linked to a Learning OutcomeAssessment: Assessment of Current Psychiatric & Medical Condition(s) or Drug Therapy-related Problem(SOAP Note on Psychiatric Evaluations for Nursing Students)

3 pts

Level 5

An optimal and thorough assessment is present for each problem.

2 pts

Level 3

An assessment is present for each problem listed but not optimal.

1 pts

Level 1

Assessment is present for 50-80% of problems

0 pts

Level 0

Less than 50% of problems include an appropriate assessment.

3 pts

This criterion is linked to a Learning OutcomeAssessment: Treatment Goals

3 pts

Level 5

Appropriate and relevant therapeutic goals for each identified problem.

2 pts

Level 3

Appropriate therapeutic goals for most identified problems (>80%).

1 pts

Level 1

Appropriate therapeutic goals for a few identified problems (50%-80%).

0 pts

Level 0

Less than 50% of problems have appropriate therapeutic goals.

3 pts

This criterion is linked to a Learning OutcomePlan: Treatment Plan

3 pts

Level 5

Specific, appropriate and justified recommendations (including drug name, strength, route, frequency, and duration of therapy) for each identified problem.(SOAP Note on Psychiatric Evaluations for Nursing Students)

2 pts

Level 3

Mostly complete and appropriate for each identified problem (>80%).

1 pts

Level 1

Partially complete and/or inappropriate for a few identified problems (50%-80%); information other than “P” provided.

0 pts

Level 0

Less than 50% of problems have an appropriate and complete treatment plan.

3 pts

This criterion is linked to a Learning OutcomePlan: Counseling, Referral, Monitoring & Follow-up

2 pts

Level 5

Specific patient education points, monitoring parameters, follow-up plan and (where applicable) referral plan for each identified problem.(SOAP Note on Psychiatric Evaluations for Nursing Students)

1 pts

Level 3

Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for >80% of identified problems.(SOAP Note on Psychiatric Evaluations for Nursing Students)

0.5 pts

Level 1

Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for a few identified problems (50%-80%).

0 pts

Level 0

Less than 50% of problems include appropriate counseling, monitoring, referral and/or follow-up plan.

SOAP Note on Psychiatric Evaluations for Nursing Students

Criteria	Clinical Notes
Informed Consent	Informed consent was given to the parent about the psychiatric interview process and psychiatric treatment. Verbal and Written consent was obtained. The patient does not have the ability/capacity to respond and appears to not understand the risk, benefits, and (Will review additional consent during treatment plan discussion)(SOAP Note on Psychiatric Evaluations for Nursing Students)
Subjective	Verify Patient           Name: TK           DOB: 10/28/2015 Minor: Yes Accompanied by: Mother Demographic: Caucasian Gender Identifier Note: Male CC: The primary concern is, “my son does not want to go to school.” HPI: Pertinent history in record:(SOAP Note on Psychiatric Evaluations for Nursing Students) TK was born prematurely. The mother reports that TK was a cry baby, and even though he does cry frequently, he is easily annoyed and loses interest in various activities except when playing with his toy car in the sitting room. He does not play with other children and prefer staying alone and watching others play from a distance, but when he joins, he is provocative and does not play “correctly.” During his first two years, TK experienced a delay in walking and talking. Currently, he mumbles words and does not communicate appropriately or as well as his peers do. He is slow in learning “stuff,” and for the past week, he has refused going to school. His teacher claims that he is “antisocial,” and does not concentrate, or participates in class-related activities. When approached with love, he is repulsive. During assessment: The patient appears irritable and throws tantrums. This behaviour has gotten worse with time. Patient activity level, attention, and concentration appear to be abnormal. The parent reports anhedonia, sleep disturbance, variable change in appetite, and energy. The parent reports increased activity, agitation, occasional panic attacks, risky activities, characterological symptoms, and anorexia. The parent does not report euphoria, obsessions, and compulsions.  SI/ HI/ AV: The parent denies any form of suicide activity, behavior, or thoughts from the patient. Allergies: NKDFA. Past Medical Hx: Medical (SOAP Note on Psychiatric Evaluations for Nursing Students)history: No history of cardiac, respiratory, endocrine, and neurological issues. Surgical history: None reported Psychiatric Hx: Previous psychiatric diagnoses: None. Describes variable course of illness. Previous medication trials: None. Safety concerns: History of Violence to Self:  None History of Violence to Others: None Mental health treatment history discussed: History of outpatient treatment: None Previous psychiatric hospitalizations: None Prior substance abuse treatment: None Trauma history: None Substance Use: NA Current Medications: No current medications.     Past Psych Med Trials: Family Medical Hx: Family Psychiatric Hx: Substance use: Parents occasionally drink alcohol. Suicides: None reported Psychiatric diagnoses/hospitalization: Mother diagnosed with depression during pregnancy. Developmental diagnoses: None reported. Social History: Occupational History: NA Military service History: NA Education history:  Kindergarten    Developmental History: Preterm birth, delayed walking, and speech. Legal History:(SOAP Note on Psychiatric Evaluations for Nursing Students) None Spiritual/Cultural Considerations: NA. ROS: Constitutional:  No fever or weight loss.  Eyes:  No vision changes or eye pain.  ENT:  No hearing changes or difficulty swallowing.  Cardiac:  No chest pain, oedema, or orthopnea.  Respiratory:  No cough or wheeze.  GI:  No abdominal pain.  GU:  No dysuria or hematuria.  Musculoskeletal:  No joint pain or swelling.  Skin:  No skin rash, lesion, or abrasions.  Neurologic:  No seizures or blackout.  Endocrine:  No polyuria or polydipsia.  Hematologic:  No blood clots or easy bleeding.  Reproductive: NA(SOAP Note on Psychiatric Evaluations for Nursing Students)
Verify Patient: Name, Assigned identification number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo.   Include demographics, chief complaint, subjective (SOAP Note on Psychiatric Evaluations for Nursing Students)information from the patient, names, and relations of others present in the interview.   HPI:  Past Medical and Psychiatric History, Current Medications, Previous Psych Med trials, Allergies. Social History, Family History. Review of Systems (ROS) – if ROS is negative, “ROS noncontributory” or “ROS negative with the exception of….”(SOAP Note on Psychiatric Evaluations for Nursing Students)
Objective	Vital Signs: Stable Temp:99.50C BP: 99/65, HR: 85, R: 23, O2:98, Pain: None, Ht: 3”5”, Wt: 30lbs, BMI: 13.9 kg/m2, BMI Range: Healthy weight.       LABS: Lab findings WNL Tox screen: NA Alcohol: NA HCG: N/A Physical Exam: MSE: The patient is uncooperative and unconversant, appears to be in distress, and disoriented. Abnormal psychomotor activity, inappropriate eye contact, anxious affect with parent’s reported mood of “irritability.” Speech: spontaneous, variable volume/tone with echolalia.   Process appears tangential, incoherent, loose associations. Cognition is limited with difficulty attending to topics, attention span & concentration, and limited knowledge. Judgment is presumed impaired . Insight is presumed impaired The patient is not able to articulate needs. The parent is committed to following through with the medication regimen. The parent is willing and able to participate in treatment and disposition.
This is where the “facts” are located. Vitals, **Physical Exam (if performed, will not be performed every visit in every setting) Include relevant labs, test results, and Include MSE, risk assessment here, and (SOAP Note on Psychiatric Evaluations for Nursing Students)psychiatric screening measure results.(SOAP Note on Psychiatric Evaluations for Nursing Students)
Assessment	DSM5 Diagnosis: with ICD-10 codes Autism Spectrum Disorder (F84.0). This is the primary Diagnosis. DSM-5 symptoms include (APA, 2013): Persistent deficits in social interactions and communicationRestricted/repetitive patterns of (SOAP Note on Psychiatric Evaluations for Nursing Students)interests/behavior/activitiesSymptoms present during early development Symptoms impair social and significant areas of functioning Intellectual Developmental Disorder (F72) This Diagnosis is refuted. DSM-5 symptoms include (APA, 2013): Deficits in intellectual functioning, including learning, reasoning, thinking, and problem-solving Deficits in adaptive functioning, including impaired developmental and sociocultural standardsSymptoms present during the development periodAttention-Deficit/Hyperactivity Disorder (F90.2) (SOAP Note on Psychiatric Evaluations for Nursing Students)This Diagnosis is refuted. DSM-5 symptoms include (APA, 2013): Hyperactivity and impulsivity inconsistent with developmental level Inattention inconsistent with developmental levelSymptoms significantly impair social and academic activitiesObsessive-compulsive disorder (F42) This Diagnosis is refuted. DSM-5 symptoms include (APA, 2013): Persistent, intrusive, unwanted, uncontrollable, and recurrent thoughts/urges/images to perform a particular activity/behavior.Repetitive behaviorsBehaviors are aimed at preventing/reducing anxiety/distress.Specific Learning Disorder (F81.81) This Diagnosis is refuted. DSM-5 symptoms include (APA, 2013): Difficulty in learning and using academic skillsLearning and academic skills are below chronological ageSymptoms begin during school-age The parent can contribute to the child’s response to psychotherapy and understand the need for psychotherapy. Reviewed potential risks & benefits, Black Box warnings, and alternatives, including declining treatment.(SOAP Note on Psychiatric Evaluations for Nursing Students)
Include your findings, Diagnosis, and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment. Informed Consent Ability(SOAP Note on Psychiatric Evaluations for Nursing Students)
Plan   (Note some items may only be applicable in the inpatient environment)  (SOAP Note on Psychiatric Evaluations for Nursing Students)	Inpatient: Psychiatric.  Do not admit as per HPI. Estimated stay: 0 Safety Risk/Plan: The patient is found to be stable and has control of behavior. The patient likely poses a minimal risk to self and a minimal  risk to others at this time.  Pharmacologic interventions: Start risperidone 0.5 mg per day. Risperidone is FDA approved for irritability and aggression in autistic children (Alsayouf et al., 2021). Risperidone is well tolerated and improves core signs and symptoms of autism. Non-pharmacologic: Refer the client to an autistic therapist for applied behavioral therapy (ABA). ABA therapists help reveal certain children behaviors to change or improve (Alsayouf et al., 2021).  The standard recommendation of ASD involves early behavioral interventions to improve socialization and support healthy development (Zwaigenbaum et al., 2015). Education: Discuss the possibility of transferring the child from the mainstream school to a specialist autistic school with the parent. Specialist schools provide the best possible individual Education Plans (IEP). Besides, staffers in such schools have special training on learning behavior, leading the children through speech therapy, social engagement, and physical education to maximize learning and successful lives. Educate the parent on how to communicate with the child, manage time, give the child information, establish a suitable home environment, and support positive behaviors. Refer the parent for Pivotal Response Treatment (PRT) to help her learn how to train her child to gain social, communication, play, and behavioral skills (Minjarez et al., 2013). Referrals: Autistic therapist for applied behavioral therapy. Follow-up: After two weeks. ☒ > 50% time spent counseling/coordination of care. Time spent in Psychotherapy  25 minutes The visit lasted 60 minutes Date: 10/28/2021    Time: 10am(SOAP Note on Psychiatric Evaluations for Nursing Students)

References

Alsayouf, H. A., Talo, H., Biddappa, M. L., & De Los Reyes, E. (2021). Risperidone or Aripiprazole Can Resolve Autism Core Signs and Symptoms in Young Children: Case Study. Children, 8(5), 318. https://doi.org/10.3390/children8050318

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing, Inc.

Minjarez, M. B., Mercier, E. M., Williams, S. E., & Hardan, A. Y. (2013). Impact of pivotal response training group therapy on stress and empowerment in parents of children with autism. Journal of Positive Behavior Interventions, 15(2), 71-78. https://doi.org/10.1177/1098300712449055

Zwaigenbaum, L., Bauman, M. L., Choueiri, R., Kasari, C., Carter, A., Granpeesheh, D., … & Natowicz, M. R. (2015). Early intervention for children with autism spectrum disorder under three years of age: recommendations for practice and research. Pediatrics, 136(Supplement 1), S60-S81. https://doi.org/10.1542/peds.2014-3667E