- Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. Please Note:
- Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
- *** See case study and template attached
CASE
Case study clinical example: Session with a client with Bipolar Disorder (fluctuations in mood)
Include under treatment and plan your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session?
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
PRAC 6665: PMHNP Care Across the Lifespan I
Faculty Name
Assignment Due Date
Subjective:
CC (chief complaint):
HPI:
Substance Current Use:
Medical History:
· Current Medications:
· Allergies:
· Reproductive Hx:
ROS:
· GENERAL:
· HEENT:
· SKIN:
· CARDIOVASCULAR:
· RESPIRATORY:
· GASTROINTESTINAL:
· GENITOURINARY:
· NEUROLOGICAL:
· MUSCULOSKELETAL:
· HEMATOLOGIC:
· LYMPHATICS:
· ENDOCRINOLOGIC:
Objective:
Diagnostic results:
Assessment:
Mental Status Examination:
Diagnostic Impression:
Reflections:
Case Formulation and Treatment Plan:
PRECEPTOR VERFICIATION:
I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.
Preceptor signature: ________________________________________________________
Date: ________________________
References
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