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Pages:
12 pages/≈3300 words
Sources:
5 Sources
Style:
APA
Subject:
Health, Medicine, Nursing
Type:
Essay
Language:
English (U.S.)
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MS Word
Date:
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Topic:

Comprehensive Psychiatric Evaluation SOAP Note

Essay Instructions:

*/ You can use any patient with a psychiatric issue, this is for a PMHNP clinical class of Psychotherapy.
For this assignment, students will create a written comprehensive psychiatric evaluation of a patient they have seen in the clinic. Each student will use the Graduate Psychotherapy Note Template Download Graduate Psychotherapy Note Template to create a detailed psychiatric evaluation document. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive psychiatric evaluation is to be written using the attached template below.
S Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) (Links to an external site.) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS); Review of Systems (ROS).
O Objective data: Medications; Allergies; Past medical history; Family history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam, (Focused), and Mental Status Exam.
A Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes.
P Plan: Pharmacologic and Nonpharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up.
Other: Incorporate current clinical guidelines NIH Clinical Guidelines (Links to an external site.)or APA Clinical Guidelines (Links to an external site.), research articles, and the role of the PMHNP in your presentation.
Reminder: It is important that you complete this assessment using your critical thinking skills. You are expected to synthesize your clinical assessment, formulate a psychiatric diagnosis, and develop a treatment plan independently. It is not acceptable to document "my preceptor made this diagnosis." An example of the appropriate descriptors of the clinical evaluation is listed below. It is not acceptable to document “within normal limits.”
Submission Instructions:
The paper is to be clear and concise and students will lose points for improper grammar, punctuation and misspelling.
The paper should be formatted per current APA and 8-10 pages in length, excluding the title, abstract and references page. Incorporate a minimum of 5 current (published within last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work.

Essay Sample Content Preview:

Title
Your name
Subject and Section
Professor’s Name
Date
Abstract
Understanding the various treatments for every psychological illness is essential for every psychiatric health practitioner. It allows him to assess the patient’s health and well-being and provide the appropriate treatment for her situation. The case presented below is about Patient AJDV seeking help for suicidal ideations before her consultation. An interview with the patient revealed that the leading cause is a combination of family problems, occupational stressors, and personal issues, among others.
Comprehensive Psychiatric Evaluation Template
With Psychotherapy Note
Encounter date: ________________________
Patient Initials: AJDV Gender: M/F/Transgender: F Age: 27 Race: American Ethnicity: American
Reason for Seeking Health Care: “I have been having persistent suicidal thoughts, and I have been planning how to kill myself for quite some time. I am afraid of what I can do to myself.”
HPI: Two months before consultation, the patient started to work as a part-time nurse practitioner in a private hospital in her neighborhood due to financial difficulties at home. She had to pay the debt that she had in college, and she also needed to support her sick mother, who was receiving palliative care secondary to liver cirrhosis. The expenses exceeded the family's monthly budget, prompting her and her siblings to seek a part-time job to help them pay for their due finances.
Initially, the patient was assigned for the first time to the pediatric department. In contrast, she was previously assigned to the adult and geriatric departments in her previous work as a nurse practitioner. Hence, the tasks were new to her. During the first week of employment, the patient was welcomed by her colleagues, and the tasks and responsibilities were explained in detail patiently by the nursing supervisor. The patient frequently asked questions about the details that she could not understand, such as some of the hospital protocols that were new to her and the use of the updated electronic healthcare system.
Moreover, she frequently asked for guidance with the skills that she was used to, especially in handling pediatric care. During the initial week, her colleagues patiently guided her, welcomed her, and entertained her questions as much as possible. The actions of her colleagues and the entire department delighted her and made her feel like it was her new home apart from her own. There was a turnover of events during the second week, and her colleagues started to treat her differently. The patient stated that "they wanted me to do everything because I was the part-timer and the tasks that I should do were not delineated from theirs." This was exacerbated by the sudden increase in the pediatric cases secondary to the increase in the number of influenza-like illness-associated diseases in the community due to the lack of compliance of the parents in the immunization of their children. Hence, the patient was given many responsibilities that were not included in her initial line of work.
Moreover, the patient spent time mostly with her work and sleeping for approximately 12 hours a day and feeling tired regardless of how muc...
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