Posted: May 15th, 2023

PMHNP Problem-Focused SOAP Note

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. Please use a psychiatric patient (example of diagnosis GAD, MDD, PTSD). Patient has to be geriatric patient older than 66 years old

PMHNP Problem-Focused SOAP Note
(Use this template for this Assignment)

Demographic Data
o Patient age and Patient’s gender identity
o 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 non-compliance 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 non-command)
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 Two (2) differential diagnoses with ICD-10 codes.
o Must include rationale using DSM-5 Criteria (Required)
o Why didn’t you pick these as a major diagnosis?
Working Diagnosis
o Final or working diagnosis (1), with ICD-10 code.
o 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 Include American Psychological Association (APA) formatted references.
o 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.
o Minimum 2 references are required.
PMHNP– SOAP Note Rubric

Criteria Ratings Pts
S
(Subjective) 10 points
Accomplished

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.

SOAP Note is complete, concise, relevant with no extraneous data. 6 points
Satisfactory

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.

Some extraneous data present with 1 minor data point missing. 4 points
Needs Improvement

Symptom analysis is not well organized or presented in a varied format. Required data is missing.

There is too much extraneous data present or 2-3 minor data points are missing. 0 points
Unsatisfactory

Symptom analysis is inadequate and is not organized. Objective or other data is mixed into the subjective data.

Important data is missing. 10 pts
O
(Objective) 10 points
Accomplished

Mental Status Exam is complete, concise, well-organized, and well-written. Includes pertinent psychiatric information. Organized by MSE list format.

No extraneous information is included. 6 points
Satisfactory

Mental Status Exam is partially incomplete, organized, and satisfactorily written. Includes pertinent psychiatric information with additional extraneous information included.

Somewhat organized in MSE list format. 4 points
Needs Improvement

Mental Status Exam is incomplete, loosely organized with improvements required. Relevant psychiatric information is omitted. 0 points
Unsatisfactory

Mental Status Exam is absent, disorganized in presentation, adheres to no specific format, or grossly omits relevant or pertinent psychiatric information. 10 pts
A
(Assessment) 10 points
Accomplished

Diagnosis and Differential Dx are correct with DSM-5 code(s) and supported by subjective and objective data.

Includes: 1 working Dx and 2 Differential Dx. 6 points
Satisfactory

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. 4 points
Needs Improvement

Diagnosis and Differential Dx are correct with DSM-5 code(s) and mostly supported by subjective and objective data.

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. 0 points
Unsatisfactory

All diagnoses (working diagnosis and differential diagnoses) are incorrect or is missing based on the subjective and objective data presented. 10 pts
P
(Plan) 10 points
Accomplished

Plan is well-organized, complete, evidence-based, and patient-centric. Fully addresses each diagnosis and is individualized to the specific patient.

*Plan requirements: prescribed medications, if any; explanation of off-label medication use, if prescribed; risks and benefits of medications identified; therapy recommendations; patient education; referral/follow-up; and health maintenance.
6 points
Satisfactory

Plan is organized, complete, evidence-based and patient-centric. Fully addresses each diagnosis and is individualized to the specific patient.

Plan is missing 1-2 of the required items. 4 points
Needs Improvement

Plan is less organized, is not based on evidence. Fails to address each diagnosis sufficiently or is not individualized or patient-centric

Plan is missing more than 2 of the required items. 0 points
Unsatisfactory

Plan is disorganized, absent, or is missing all the required items. 10 pts
Total 40 pts