NRNP 6665 Week 4 Assignment: PMHNP Across the Lifespan I: Assessing, Diagnosing, and Treating Adults With Mood Disorders -Comprehensive SOAP Note for Petunia Park Case Study
NRNP 6665 Week 4 Assignment: PMHNP Across the Lifespan I: Assessing, Diagnosing, and Treating Adults With Mood Disorders -Comprehensive SOAP Note for Petunia Park Case Study
NRNP 6665: PMHNP Across the Lifespan I: Assessing, Diagnosing, and Treating Adults With Mood Disorders
It is important for the PMHNP to have a comprehensive understanding of mood disorders in order to assess and accurately formulate a diagnosis and treatment plan for patients presenting with these disorders. Mood disorders may be diagnosed when a patient’s emotional state meets the diagnostic criteria for severity, functional impact, and length of time. Those with a mood disorder may find that their emotions interfere with work, relationships, or other parts of their lives that impact daily functioning. Mood disorders may also lead to substance abuse or suicidal thoughts or behaviors, and although they are not likely to go away on their own, they can be managed with an effective treatment plan and understanding of how to manage symptoms.
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In this Assignment you will assess, diagnose, and devise a treatment plan for a patient in a case study who is presenting with a mood disorder.
To Prepare
• Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
• Review the video, Case Study: Petunia Park. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
Walden University. (2021). Case study: Petunia Park. Walden University Blackboard. https://waldenu.instructure.com
• Consider what history would be necessary to collect from this patient.
• Consider what interview questions you would need to ask this patient.
• Consider patient diagnostics missing from the video:
Provider Review outside of interview:
Temp 98.2 Pulse 90 Respiration 18 B/P 138/88
Laboratory Data Available: Urine drug and alcohol screen negative. CBC within normal ranges, CMP within normal ranges. Lipid panel within normal ranges. Prolactin Level 8; TSH 6.3 (H)
The Assignment
Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:
• Subjective: What details did the patient provide regarding their chief complaint and symptomatology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
• Objective: What observations did you make during the psychiatric assessment?
• Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
• Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.
• Reflection notes: Reflect on this case. Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
• Utilize Turnit in Drafts for originality report before final submission of this assignment.
Submit your Focused SOAP Note.
GRADING RUBRIC
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NRNP_6665_Week4_Assignment_Rubric
NRNP_6665_Week4_Assignment_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning Outcome Create documentation in the Focused SOAP Note Template about the patient in the case study. In the Subjective section, provide: • Chief complaint• History of present illness (HPI)• Past psychiatric history• Medication trials and current medications• Psychotherapy or previous psychiatric diagnosis• Pertinent substance use, family psychiatric/substance use, social, and medical history• Allergies• ROS 15 to >13.0 pts
Excellent
The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. 13 to >11.0 pts
Good
The response accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. 11 to >10.0 pts
Fair
The response describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis but is somewhat vague or contains minor innacuracies. 10 to >0 pts
Poor
The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Or the subjective documentation is missing.
15 pts
This criterion is linked to a Learning Outcome In the Objective section, provide:• Review of Systems (ROS) documentation and relate if pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses 15 to >13.0 pts
Excellent
The response thoroughly and accurately documents the patient’s ROS for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented. 13 to >11.0 pts
Good
The response accurately documents the patient’s ROS for pertinent systems. Diagnostic tests and their results are accurately documented. 11 to >10.0 pts
Fair
Documentation of the patient’s ROS is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor inaccuracies. 10 to >0 pts
Poor
The response provides incomplete or inaccurate documentation of the patient’s ROS. Systems may have been unnecessarily reviewed. Or the objective documentation is missing.
15 pts
This criterion is linked to a Learning Outcome In the Assessment section, provide:• Results of the mental status examination, presented in paragraph form• At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case. 20 to >17.0 pts
Excellent
The response thoroughly and accurately documents the results of the mental status exam. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected. 17 to >15.0 pts
Good
The response accurately documents the results of the mental status exam. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the disorders selected. 15 to >13.0 pts
Fair
The response documents the results of the mental status exam with some vagueness or innacuracy. Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vagueness or innacuracy. 13 to >0 pts
Poor
The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or the assessment documentation is missing.
20 pts
This criterion is linked to a Learning Outcome In the Plan section, provide:• Your plan for psychotherapy• Your plan for treatment and management, including alternative therapies. Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. • Incorporate one health promotion activity and one patient education strategy. 25 to >22.0 pts
Excellent
The response provides an evidence-based, detailed, and appropriate plan for psychotherapy for the patient. The response provides an evidence-based, detailed, and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A strong rationale for the plan is provided that demonstrates critical thinking and content understanding. … The response includes at least one evidence-based health promotion activity and one evidence-based patient education strategy. 22 to >19.0 pts
Good
The response provides an evidence-based and appropriate plan for psychotherapy for the patient. The response provides an evidence-based and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. An adequate rationale for the plan is provided. … The response includes at least one health promotion activity and one patient education strategy. 19 to >17.0 pts
Fair
The response provides a somewhat vague or inaccurate plan for psychotherapy for the patient. The response provides a somewhat vague or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is weak or general. … The response includes one health promotion activity and one patient education strategy, but it may contain some vagueness or innacuracy. 17 to >0 pts
Poor
The response provides an incomplete or inaccurate plan for psychotherapy for the patient. The response provides an incomplete or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is inaccurate or missing. … The health promotion and patient education strategies are incomplete or missing.
25 pts
This criterion is linked to a Learning Outcome • Reflect on this case. Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.). 5 to >4.0 pts
Excellent
Reflections are thorough, thoughtful, and demonstrate critical thinking. 4 to >3.5 pts
Good
Reflections demonstrate critical thinking. 3.5 to >3.0 pts
Fair
Reflections are somewhat general or do not demonstrate critical thinking. 3 to >0 pts
Poor
Reflections are incomplete, inaccurate, or missing.
5 pts
This criterion is linked to a Learning Outcome Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old). 10 to >8.0 pts
Excellent
The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making. 8 to >7.0 pts
Good
The response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study. 7 to >6.0 pts
Fair
Three evidence-based resources are provided to support the assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification. 6 to >0 pts
Poor
Two or fewer resources are provided to support the assessment and diagnosis decisions. The resources may not be current or evidence based.
10 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting – The paper follows correct APA format for parenthetical/in-text citations and reference list. 5 to >4.0 pts
Excellent
Uses correct APA format with no errors 4 to >3.5 pts
Good
Contains a few (one or two) APA format errors 3.5 to >3.0 pts
Fair
Contains several (three or four) APA format errors 3 to >0 pts
Poor
Contains many (five or more) APA format errors
5 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and punctuation 5 to >4.0 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors 4 to >3.5 pts
Good
Contains a few (one or two) grammar, spelling, and punctuation errors 3.5 to >3.0 pts
Fair
Contains several (three or four) grammar, spelling, and punctuation errors 3 to >0 pts
Poor
Contains many (five or more) grammar, spelling, and punctuation errors that interfere with the reader’s understanding
5 pts
Total Points: 100
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