Description
These are the instructions: Submit a Problem-Focused SOAP note here for grading. You must use an actual patient from your clinical practicum. Review the rubric for more information on how your assignment will be graded. Be sure to use the SOAP note template for your program and view the rubric associated with your program for details on how your assignment will be graded.
I attached 2 a template, an example, plus the rubric.
Patient information:
Diagnostic Codes: F25.0 | Schizoaffective disorder, bipolar type
Patient Age: 68 Years
Race Category (NCI Classification): Hispanic
Gender: Male
Medication: List Medication Name, Dosage, Frequency, and Refill.: Risperidone 1mg take 1 tablet by mouth twice a day for psychosis.
Depakote DR 500mg take 1 tablet by mouth twice a day for mood.
Trazadone 100mg take 1 tablet by mouth at bedtime for sleep.
Vistaril 50 mg take one tablet by mouth every 8 hours for anxiety.
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PMHNP– SOAP Note Rubric
Criteria
S
(Subjective)
O
(Objective)
A
(Assessment)
Ratings
10 points
Accomplished
6 points
Satisfactory
4 points
Needs Improvement
0 points
Unsatisfactory
Symptom analysis is
well organized in a
SOAP format, with
C/C, Past Psychiatric
Hx, Social Hx, and
other pertinent past
and current
diagnostic details.
Symptom analysis is
well organized in a
SOAP format, with
C/C, Past Psychiatric
Hx, Social Hx, and
other pertinent past
and current
diagnostic details.
Symptom analysis is
not well organized or
presented in a varied
format. Required data
is missing.
Symptom analysis is
inadequate and is
not organized.
Objective or other
data is mixed into
the subjective data.
SOAP Note is
complete, concise,
relevant with no
extraneous data.
10 points
Accomplished
Some extraneous
data present with 1
minor data point
missing.
6 points
Satisfactory
Mental Status Exam is
complete, concise,
well-organized, and
well-written. Includes
pertinent psychiatric
information.
Organized by MSE list
format.
Mental Status Exam
is partially
incomplete,
organized, and
satisfactorily written.
Includes pertinent
psychiatric
information with
additional extraneous
information included.
Important data is
missing.
4 points
Needs Improvement
0 points
Unsatisfactory
Mental Status Exam is
incomplete, loosely
organized with
improvements
required. Relevant
psychiatric information
is omitted.
Mental Status Exam
is absent,
disorganized in
presentation,
adheres to no
specific format, or
grossly omits
relevant or pertinent
psychiatric
information.
No extraneous
information is
included.
Somewhat organized
in MSE list format.
10 points
Accomplished
6 points
Satisfactory
4 points
Needs Improvement
0 points
Unsatisfactory
Diagnosis and
Differential Dx are
correct with DSM-5
code(s) and supported
by subjective and
objective data.
Diagnosis and
Differential Dx are
correct with DSM-5
code(s) and mostly
supported by
subjective and
objective data.
Diagnosis and
Differential Dx are
correct with DSM-5
code(s) and mostly
supported by
subjective and
objective data.
Missing at least one
(1) pertinent
differential diagnosis
not listed according
to subjective and
objective data.
Working diagnosis is
correct.
All diagnoses
(working diagnosis
and differential
diagnoses) are
incorrect or is
missing based on
the subjective and
objective data
presented.
Includes: 1 working
Dx and 2 Differential
Dx.
P
(Plan)
There is too much
extraneous data
present or 2-3 minor
data points are
missing.
10 points
Accomplished
6 points
Satisfactory
Missing up to two (2)
pertinent differential
diagnoses based on
subjective and
objective data
presented. Or
differential diagnoses
are adequate with an
incorrect working
diagnosis.
4 points
Needs Improvement
Plan is well-organized,
complete, evidence-
Plan is organized,
complete, evidencebased and patient-
Plan is less organized,
is not based on
evidence. Fails to
Pts
10
pts
0 points
Unsatisfactory
Plan is disorganized,
absent, or is missing
10
pts
10
pts
10
pts
based, and patientcentric. Fully
addresses each
diagnosis and is
individualized to the
specific patient.
*Plan requirements:
prescribed
medications, if any;
explanation of offlabel medication use,
if prescribed; risks
and benefits of
medications
identified; therapy
recommendations;
patient education;
referral/follow-up;
and health
maintenance.
Total
centric. Fully
addresses each
diagnosis and is
individualized to the
specific patient.
Plan is missing 1-2 of
the required items.
address each diagnosis
sufficiently or is not
individualized or
patient-centric
all the required
items.
Plan is missing more
than 2 of the required
items.
40
pts
PMHNP Problem-Focused SOAP Note
(Use this template for this Assignment)
Demographic Data
o
o
Patient age and Patient’s gender identity
MUST BE HIPAA compliant.
Subjective
Chief Complaint (CC):
o
Place the patient’s CC complaint in Quotes
History of Present Illness (HPI):
o Reason for an appointment today.
o The events that led to hospitalization or clinic visits today.
o Include symptoms, relieving factors, and past compliance or noncompliance with medications
o Any adverse effects from past medication use
o Sleep patterns – number of hours of sleep per day, early wakefulness, not
being able to initiate sleep, not able to stay asleep, etc.
o Suicide or homicide thoughts present
o Any self-care or Activity of Daily Living (ADL) such as eating, drinking
liquids, self-care deficits or issues noted?
o Presence/description of psychosis (if psychosis, command or noncommand)
Past Psychiatric History (PSH):
o Past psychiatric diagnoses
o Past hospitalizations
o Past psychiatric medications use
o Any non-compliance issues in the past?
o Any meds that didn’t work for this patient?
Family History of Psychiatric Conditions or Diagnoses:
o Mother/father, siblings, grandparents, or direct relatives
Social History:
o 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:
o
to medications, foods, chemicals, and other.
Review of Systems (ROS) (Physical Complaints):
o Any physical complaints by body system? (Respiratory, Cardiac, Renal, etc.)
Objective
Mental Status Exam:
o This is not physical exam.
o Mini-Mental Status Exam (MMSE) – Full exam
Assessment (Diagnosis)
Differentials
o
o
o
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
o
o
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):
o Pharmacologic: Include full information for each medication(s) prescribed
o Refill Provided: Include full information for each medication(s) refilled
Patient Education:
o including specific medication teaching points
o Was risk versus benefit of current treatment plan addressed for meds or
treatment
o Risk versus benefit of non-FDA approved for working diagnosis – Off-label use
of medication education to patient addressed?
Prognosis:
o Make Decision for prognosis: Good, Fair, Poor
o Provide brief statement lending support for or against the decided prognosis.
Therapy Recommendations:
o Type(s) of therapy recommended.
Referral/Follow-up:
o Did you recommend follow-up with Psychiatrist, PCP, or other specialist or
healthcare professionals?
o When is the subsequent follow-up?
o Include rationale for the F/U recommendation or referral.
Reference(s):
o
o
o
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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