Due 12-14-24 MUST use attached template

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Due12-14-24MUSTuseattachedtemplate.docx

Due 12-14-24 MUST use attached template Unit 15-Final Case Formulation

Instructions

Select a pediatric/adolescent client or case that you have worked with either in your current nursing practice or your PMHNP student clinical setting. Ensure that you correctly remove the appropriate information (name, etc.) to remain HIPAA compliant. 

· Prepare a full mental health evaluation on your pediatric/adolescent client. Use the resources presented in the course to help guide your evaluation. Kaplan & Saddock’s  Synopsis of Psychiatry has a robust list of the categories of information you should collect and present in your evaluation report (5.1. Parts of the Initial Psychiatric Interview). This should include the following: 

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· A full psychiatric, physical, social, family, and birth and developmental history including verbal reports of the client, your observations of the client, and a summary of any diagnostic aids that you have used. 

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· The use of at least one psychiatric screening or assessment tool from the literature to assist in your assessment of the client 

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· A full physical assessment in addition to the mental status exam and psychiatric history 

· Develop a DSM-5 diagnostic assessment: 

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· Support your diagnosis through a thoughtful, evidence-based rationale of the data collected in your evaluation. 

· Propose a practical, evidence-based plan of care: 

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· Keep in mind the role of the psychiatric-mental health nurse practitioner is to assess all aspects of the patient’s health status, including  health promotion, and  disease prevention. 

· Psychiatric care is interdisciplinary. Your plan of care may include the use of other mental health professionals for the delivery of appropriate care.

· For example, someone who has chronic back pain, and has been out of work may have these factors contributing to his or her depression and may require a pain specialist and social services to address that aspect of the client’s poor psychological functioning. 

Requirements 

· Support your assessment, diagnosis, treatment, and management plan with appropriate literature citations. 

· The SOAP note should be no more than ten pages in length, not including the title and reference pages. 

· Use current APA formatting and citations. 

· Acronyms should not be used. 

· The assessment must be well written and be of professional quality. It must be clear, and well developed, free of spelling, grammatical, and syntactical errors, and in full sentences format. 

All work should be original and submitted as a Word document unless otherwise indicated in the assignment instructions. ALL assignments need to be APA 7 format and accompanied title page in APA 7th edition format in order that the work would be properly identified for the student, the course, and the assignment. Work submitted without a title page will receive a grade of 0.

Complete this assignment and submit it to this assignment dropbox by Sunday at 11:59 pm CT.

Estimated time to complete: 6 hours

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HUInitialMHASOAPNoteTemplate13.docx

Initial Psychiatric Interview/SOAP Note Template

There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to develop your style of SOAP in the psychiatric practice setting.

Criteria

Clinical Notes

Informed Consent

Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion)

Subjective

Verify Patient

Name:

DOB:

Minor:

Accompanied by:

Demographic:

Gender Identifier Note:

CC:

HPI:

Pertinent history in record and from patient: X

During assessment: Patient describes their mood as X and indicated it has gotten worse in TIME.

Patient self-esteem appears fair, no reported feelings of excessive guilt,

no reported anhedonia, does not report sleep disturbance, does not report change in appetite, does not report libido disturbances, does not report change in energy,

no reported changes in concentration or memory.

Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. Patient does not report excessive fears, worries or panic attacks.

Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a characterological nature.

SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors.

Allergies: NKDFA.

(medication & food)

Past Medical Hx:

Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury.

Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C.

Surgical history no surgical history reported

Past Psychiatric Hx:

Previous psychiatric diagnoses: none reported.

Describes stable course of illness.

Previous medication trials: none reported.

Safety concerns:

History of Violence to Self: none reported

History of Violence t o Others: none reported

Auditory Hallucinations:

Visual Hallucinations:

Mental health treatment history discussed:

History of outpatient treatment: not reported

Previous psychiatric hospitalizations: not reported

Prior substance abuse treatment: not reported

Trauma history: Client does not report history of trauma including abuse, domestic violence, witnessing disturbing events.

Substance Use: Client denies use or dependence on nicotine/tobacco products.

Client does not report abuse of or dependence on ETOH, and other illicit drugs.

Current Medications: No current medications.

(Contraceptives):

Supplements:

Past Psych Med Trials:

Family Medical Hx:

Family Psychiatric Hx:

Substance use

Suicides

Psychiatric diagnoses/hospitalization

Developmental diagnoses

Social History:

Occupational History: currently unemployed. Denies previous occupational hx

Military service History: Denies previous military hx.

Education history: completed HS and vocational certificate

Developmental History: no significant details reported.

(Childhood History include in utero if available)

Legal History: no reported/known legal issues, no reported/known conservator or guardian.

Spiritual/Cultural Considerations: none reported.

ROS:

Constitutional: No report of fever or weight loss.

Eyes: No report of acute vision changes or eye pain.

ENT: No report of hearing changes or difficulty swallowing.

Cardiac: No report of chest pain, edema or orthopnea.

Respiratory: Denies dyspnea, cough or wheeze.

GI: No report of abdominal pain.

GU: No report of dysuria or hematuria.

Musculoskeletal: No report of joint pain or swelling.

Skin: No report of rash, lesion, abrasions.

Neurologic: No report of seizures, blackout, numbness or focal weakness. Endocrine: No report of polyuria or polydipsia.

Hematologic: No report of blood clots or easy bleeding.

Allergy: No report of hives or allergic reaction.

Reproductive: No report of significant issues. (females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…)

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 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…”

Objective

Vital Signs: Stable

Temp:

BP:

HR:

R:

O2:

Pain:

Ht:

Wt:

BMI:

BMI Range:

LABS:

Lab findings WNL

Tox screen: Negative

Alcohol: Negative

HCG: N/A

Physical Exam:

MSE:

Patient is cooperative and conversant, appears without acute distress, and fully oriented x 4. Patient is dressed appropriately for age and season. Psychomotor activity appears within normal.

Presents with appropriate eye contact, euthymic affect - full, even, congruent with reported mood of “x”. Speech: spontaneous, normal rate, appropriate volume/tone with no problems expressing self.

TC: no abnormal content elicited, denies suicidal ideation and denies homicidal ideation. Process appears linear, coherent, goal-directed.

Cognition appears grossly intact with appropriate attention span & concentration and average fund of knowledge.

Judgment appears fair . Insight appears fair

The patient is able to articulate needs, is motivated for compliance and adherence to medication regimen. Patient is willing and able to participate with treatment, disposition, and discharge planning.

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 psychiatric screening measure results.

Assessment

DSM5 Diagnosis: with ICD-10 codes

Dx: -

Dx: -

Dx: -

Patient has the ability/capacity appears to respond to psychiatric medications/psychotherapy and appears to understand the need for medications/psychotherapy and is willing to maintain adherent.

Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment.

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

Plan

(Note some items may only be applicable in the inpatient environment)

Inpatient:

Psychiatric. Admits to X as per HPI.

Estimated stay 3-5 days

Safety Risk/Plan: Patient is found to be stable and has control of behavior. Patient likely poses a minimal risk to self and a minimal risk to others at this time.

Patient denies abnormal perceptions and does not appear to be responding to internal stimuli.

Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic:

· No changes to current medication, as listed in chart, at this time

· or…Zoloft is an excellent option for many women who experience any menstrual cycle complaints. I usually start at 50 mg and move to 100 week 6-8. f/u within 2 weeks initially then every 6-8 weeks.

· Psychotherapy referral for CBT

Education, including health promotion, maintenance, and psychosocial needs

· Importance of medication

· Discussed current tobacco use. NRT not indicated.

· Safety planning

· Discuss worsening sx and when to contact office or report to ED

Referrals: endocrinologist for diabetes

Follow-up, including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit 2 weeks

☒ > 50% time spent counseling/coordination of care.

Time spent in Psychotherapy 18 minutes

Visit lasted 55 minutes

Billing Codes for visit:

XX

XX

XX

____________________________________________

NAME, TITLE

Date: Click here to enter a date. Time: X