PRAC 6665 WK3 SOAP NOTE
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Wk_3_Assgn_SOAP.docx.pdf
Week 3: Focused SOAP Note and Patient Case Presentation
College of Nursing-PMHNP, Walden University
NRNP 6665: PMHNP Care Across the Lifespan 1 Practicum
Introduction
Every patient's treatment begins with a full health assessment, because the plan of care
and every mental intervention are all dependent on the information gathered at the initial meeting
with the patient. In this situation, the assessment was documented after the patient was evaluated,
and a diagnostic impression was formed based on the information gained from the patient during
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the evaluation. A 30 years old White female attending a follow up on tele psych appointment.
Patient states that she is doing well with meds. Patient is taking all prescribed
medications: Gabapentin 100mg PO 3 times per day, Wellbutrin 300mg PO daily, Effexor 112mg
PO daily and will continue with the above listed medications as they are effective.
Subjective:
CC: "Sometimes I get really anxious, sometimes depressed. It's hard to describe my feelings".
HPI: Amy a 30 years old White female attending a follow up on tele psych appointment. Patient
states that she is doing well with meds. Patient is taking Gabapentin 100mg PO 3 times per day,
Wellbutrin 300mg PO daily, Effexor 112mg PO daily. Patient admits to the use of Weed and
Alcohol daily. Admits that she took alcohol last night and that has been going on for the last 10
days. States that weed makes her more social, calm, get things done. The patient was evaluated
by the Nurse Practitioner student. The patient describes her mood as good. Her affect is restricted
but adequate. Patient denies SI/HI. Following the note on prior meeting with patient and the
psychiatrist, patient is coping well with her mental condition.
Substance Current Use and History: Patient admit to use of alcohol and weed. Admits that she
took alcohol last night and that has been going on for the last 10 days. States that weed makes
her more social, calm, get things done.
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Medical History: Patient denies any medical history
Current Medication: Gabapentin 100mg PO 3 times per day, Wellbutrin 300mg PO daily,
Effexor 112mg PO daily
Allergies: No known drug allergies, food or seasonal allergies
Reproductive History: Patient is presently sexually active, practices safe sex. No history of
abortion or miscarriages
ROS:
GENERAL: Well attired, appeared nervous and shy during the session.
HEENT: There is no swelling or redness in the eyes. Denies having an ear condition.
No abnormalities or disfigurements were found in the nose. There is no deviation or swelling in
the throat or neck.
SKIN: no discoloration noted or history of skin condition
CARDIOVASCULAR: Within typical limits for heart rate and blood pressure
PULMONARY: There are no aberrant noises in any of the lungs; sounds all clear
GASTROINTESTINAL: able to move bowels without no problem or discomfort
GENITOURINARY: continent times two, and able to void without problem
NEUROLOGICAL: alert, oriented, to person, place, time, and circumstance
MUSCULOSKELETAL: moves all upper extremities with no deformities
HEMOTOLOGICAL: no blood disorder reported or listed in history
LYMPATHIC : no condition reported or enlarged nodes
ENDOCRINOLOGY: no condition reported or reported of cold or heat intolerance
Objective:
Diagnostic Results: No diagnostic test was required during this assessment session
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Assessment:
Mental Status Examination
Amy a 30-years-old White female who looks like the above stated age was scheduled for
a psych tele evaluation session. Patient is focused, alert, follows all orders, and accurately
answers all questions The patient was nice and well-dressed, yet appeared uneasy and fidgety.
Although there were no acute psychosis or mood symptoms, the patient appeared concerned.
Denies any current or previous history of suicide. Denies any current or previous or
present history of suicide. Denies having any homicidal ideas or hearing voices or thoughts that
might cause harm to people. All of memories are intact, however patient is extremely forgetful
and have poor focus due to ADHD.
Diagnostic Impression
Attention Deficit Hyperactivity Disorder (ADHD): Limited attention, hyperactivity, inability
to focus for long periods of time, difficulties at school or at work, worries, forgetfulness, anxiety,
excessive fidgeting, wanders off task, lacks tenacity, is disorganized, and takes hasty acts are all
symptoms of ADHD in children and adults (Sadock, et al., 2014). Patients with this disorder
must have the following symptoms, according to the DSM-5: a history of impulsive behavior,
difficulties at school or at work, forgetfulness, nervousness, excessive fidgeting, wandering off
track, lacks tenacity, has problems maintaining attention, is disorganized, makes casual mistakes
in schooling or at work, dislikes tasks that require concentration, misplaces things, patient stating
that weed makes her more social, calm, and get things done.
Anxiety Disorder: Anxiety Disorder is a mental health condition that is more than just a worry
or fear, and it can have a significant impact on job, relationships, and other aspects of one's life
(Bachem & Casey, 2018). According to the DSM-5, an individual must meet certain criteria in
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order to be diagnosed with anxiety disorder: edginess, irritability, feeling as if the mind is going
blank, unsatisfying sleep, limited attention, troubled relationships, difficulty at school or work,
forgetful, excessively fidgets, wanders off task, has difficulty concentrating etc. (American
Psychiatric Association, 2013). In the case of our patient Ms. Amy, this is demonstrated by the
patient admitting that she forgets to finish work, loses her temper, fidgets while sitting for no
apparent reason, can't sit still for long periods of time, misplaces things, or forgets to read, and
the patient claiming that weed makes her more social, calm, and efficient.
Depressive Disorder 311 (F32.9): Changes in energy level, anxiety, wanders off task, lacks
tenacity, has problems sustaining attention, self-esteem difficulties, isolates self for no cause,
change in sleep pattern, loss of interest in activities, guilt, impatience, misplacing items, and so
on are all symptoms of depression (Bachem & Casey, 2018). Change in energy level, wanders off
task, lacks persistence, poor self-esteem, anxiety, isolation, appetite change, forgetfulness, not
completing assigned chores at work or school, feeling guilty, and loss of energy are all signs and
symptoms of Depressive Disorder, according to the DSM-5 (American Psychiatric Association,
2013). The following explanation correlates with the behaviors reported by our patient, Ms.
Amy, with the symptoms listed above. This is demonstrated by the patient's admission that she
forgets to finish her work and that she uses weed and alcohol on a daily basis. She admits to
drinking last night and has been doing so for the past ten days, patient claiming that weed makes
her more social, calm, and efficient.
Reflection
One thing I could have done differently as a PMHNP is to begin the interview by greeting
the patient and asking questions unrelated to the scheduled meeting, which would assist to create
a congenial atmosphere. Then, without appearing like I have a predetermined notion about the
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patient's personality, illness, or what the practitioner said about the patient, ask open-ended
questions. Also, inquire if the patient would want to speak with the provider privately if there is
something she would like to share with the provider rather than the clinical rotation
student. Then learn about the patient's pressures, depression, identity, and sexual orientation
issues. As a PHMNP, it is critical to create an accepting environment for all patients during an
interview; this will assist my patients understand that this is a place to help them heal and that
they are accepted despite of their mistakes or imperfections. Trust, respect for diversity, equity,
fairness, and social justice are all elements of cultural competence that must be considered
throughout any form of interview or encounter between a healthcare practitioner and a patient
(Sadock et al., 2014).
Substance addiction resources should be made available to this patient, since it is clear
that she uses substances on a daily basis in order to complete her daily tasks. If it hasn't already,
this can lead to substance abuse. Substance abuse education focuses on teaching people about
drug and alcohol abuse, as well as how to avoid, quit, or seek help for substance use disorders.
Case Formation and Treatment Plan
The patient will undergo 15 minutes of group supportive therapy every day from Monday
to Friday. The patient will receive an instructional brochure, as well as assignments and a follow-
up visit, on the issues discussed.
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There are two phone lines supplied to the patient: 911 for immediate assistance and the Client's
Crisis Line. For mutual and collaborative understanding, medical and therapist reports were
evaluated.
There was plenty of opportunity for questions and answers throughout this 60-minute session.
The patient was given supportive listening, and he appeared to understand what was said. She
believes in the treatment plan and continues to follow it.
Consult your PCP if necessary, or if you have any questions or concerns concerning the start of
any undesirable or unexpected side effects.
As part of the treatment, group counseling was ordered and implemented.
Substance abuse resources was provided; list of available places was given to patient.
The patient will be psychiatrically stable and able to live in the community for extended periods
of time while maintaining a better quality of life.
Any other supplier recommendations: There are none.
Return to psych tele appointments: every 90 days.
Conclusion
During an interview, a PMHNP student must attempt to produce their own facts or
information from patients in order to give tailored or personalized care, independent of the
information provided by the preceptor about the patient prior to the interview. Prejudices about
the patient's personality, health, or what the practitioner says about the patient should be
avoided. Also, inquire if the patient would like to speak privately if there is anything she would
like to share privately. Then learn about the patient's pressures, depression, identity, and sexual
orientation issues. More so, it's critical to know what distinguishes one psychological condition
from another. Treatment methods are beneficial since they assist people in managing their
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illnesses. Determining an individual's illness type could have led to more reliable and accurate
treatment alternatives; treatment approaches are beneficial since they help people regulate their
conditions. An unbiased individual is not swayed by personal feelings or beliefs since the facts
of the issue are weighed. When dealing with customers, as a potential PMHNP, I must retain
objectivity. From an ethical sense, I must emphasize that people should be assisted rather than
criticized or treated unfairly.
References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental
Disorders, fifth edition DSM-5 American Psychiatric Association, 2013.
Bachem, R., & Casey, P. (2018). Adjustment disorder: A diagnosis whose time has come.
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Journal of Affective Disorders, 227, 243-253. https://doi.org/10.1016/j.jad.2017.10.034
Adjustment disorder: A diagnosis whose time has come
Adjustment disorder is among the most frequently diagnosed mental disorders in clinical practic
e although it has received littleacademic attention an…
doi.org Sadock, B.J., Sadock, V.A., & Ruiz, P. (2014). Kaplan and Sadock’s synopsis of psychiatry:
Behavioral sciences/clinical psychiatry (11 th ed.). Philadelphia, PA: Wolters Kluwer.
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