Focused SOAP Note Evaluation

Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will document information about a patient that you examined during the last three weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.

Record yourself presenting the complex case for your clinical patient.

Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video. 

5. PM is a 64-year-old male veteran of the marine corps. Patient presents with Depression, Schizophrenia, Bipolar, Insomnia and PTSD. The patient reports increased feelings of emptiness, isolates much more than before, and increased restlessness at night. Patient reports he sleeps poorly and feels sleepy during morning activities, denies any changes in his appetite, and endorses euthymic mood. Pt stated I need some therapy; I need to talk to someone. I need help with my mental state”. Patient reports he was referred to the clinic by his counsellor. Patient came to this appointment in person.  Sleep routine is irregular and endorses trouble staying asleep. Patient endorses getting about 4 hours of sleep on average at night. Patient further endorses lack of energy to do things but endorses much motivation to see a different outcome to his current situation. Patient´s concentration is poor. His appetite fluctuates with reported 11lbs weight gain in the last month. Patient endorses feelings of hopelessness, helplessness, and worthlessness. Patient reports he has abused crack cocaine and alcohol in the past but is 2 weeks sober. Patient reports history of trauma and abuse. Patient denies any suicide ideation or plan or thoughts or homicidal ideation.  Patient reports that he was diagnosed with PTSD about 1981. Patient also endorses a previous diagnosis of depression, Bipolar and Schizophrenia in 6th grade. Patient denies any diagnosis of sleep apnea. The plan of care of this patient was to start seeing a therapist. An appointment was scheduled next week for pt to see a therapist and medications was prescribed to help with mood and anxiety.