PRAC 6665 Week 3 Assignment: Focused SOAP Note and Patient Case Presentation
Walden University PRAC 6665 Week 3 Assignment: Focused SOAP Note and Patient Case Presentation-Step-By-Step Guide
This guide will demonstrate how to complete the Walden University PRAC 6665 Week 3 Assignment: Focused SOAP Note and Patient Case Presentation assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.
How to Research and Prepare for PRAC 6665 Week 3 Assignment: Focused SOAP Note and Patient Case Presentation
Whether one passes or fails an academic assignment such as the Walden University PRAC 6665 Week 3 Assignment: Focused SOAP Note and Patient Case Presentation depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.
After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.
How to Write the Introduction for PRAC 6665 Week 3 Assignment: Focused SOAP Note and Patient Case Presentation
The introduction for the Walden University PRAC 6665 Week 3 Assignment: Focused SOAP Note and Patient Case Presentation is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.
How to Write the Body for PRAC 6665 Week 3 Assignment: Focused SOAP Note and Patient Case Presentation
After the introduction, move into the main part of the PRAC 6665 Week 3 Assignment: Focused SOAP Note and Patient Case Presentation assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.
Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.
How to Write the Conclusion for PRAC 6665 Week 3 Assignment: Focused SOAP Note and Patient Case Presentation
After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.
How to Format the References List for PRAC 6665 Week 3 Assignment: Focused SOAP Note and Patient Case Presentation
The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.
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Sample Answer for PRAC 6665 Week 3 Assignment: Focused SOAP Note and Patient Case Presentation
Subjective:
CC (chief complaint): “I have been feeling overwhelmed and anxious ever since I lost my job three months ago.”
HPI: M.A. is a 39-year-old male Asian patient who visited the clinic complaining of increased anxiety, sadness, and irritability for the past three months after having lost his job. He mentions sleeping difficulties, a lack of interest in things he likes to do, and trouble concentrating. He mentions experiencing irritability and occasional outbursts of anger, which has affected his relationship with his wife and siblings. He points out that it hurts him to know he cannot provide for his family, and he also feels overwhelmed by the prospect of finding new employment.
Substance Current Use: The patient denies the use of alcohol, tobacco, or any other illicit drug.
Medical History:
- Current Medications: The patient takes 10 mg of Lisinopril daily for hypertension. He has been on this medication for the last six months.
- Allergies: The patient has no known allergies.
- Reproductive Hx: The patient is currently married to one wife, and they have two children. The two are still living with their parent while pursuing their junior school education.
ROS:
- GENERAL: The patient reported feeling weak and tired, having sleeping difficulties, and significant weight loss.
- HEENT: No headache or trauma, no lumps, bumps, or lesions. No double vision or vision change, eye discharge, redness or pain, hearing loss, or ear discharge or pain. No nasal discharge or congestion. No dysphagia or hoarseness.
- SKIN: The patient has no itch, acne, or rashes.
- CARDIOVASCULAR: No edema or palpitations, chest discomfort, pain, or pressure.
- RESPIRATORY: No shortness of breath or cough.
- GASTROINTESTINAL: No abdominal pain, nausea, or vomiting. The patient reported no changes in appetite.
- GENITOURINARY: No dysuria or hematuria
- NEUROLOGICAL: The patient reported no headaches, dizziness, or seizures.
- MUSCULOSKELETAL: No muscle weakness or joint pain.
- HEMATOLOGIC: No history of bleeding or bruising.
- LYMPHATICS: No swollen lymph nodes on his body.
- ENDOCRINOLOGIC: No heat or cold intolerance, no polyuria or polydipsia.
Objective
Diagnostic results: No laboratory tests were performed.
Assessment:
Mental Status Examination: The patient is a 39-year-old male of Asian origin. The patient presents to the health care facility for a medical assessment. The Patient appears well-dressed. He looks hopeless, helpless, and full of anxiety. He also appears tensed and restless, filled with negative thoughts about finance and employment search. He has no suicidal thoughts or homicidal ideation.
Diagnostic Impression:
Adjustment Disorder with Anxiety and Depressed Mood– This is a condition where the patient presents with emotional and behavioral symptoms, such as anxiety, depressed mood, irritability, difficulty sleeping, and loss of interest in things once liked (Winter et al., 2020). This patient’s symptoms started three months ago, brought about by a significant stressor of losing his job. Based on the DSM-V criteria, these symptoms displayed by the patient point to adjustment disorder. His symptoms are causing significant impairment in social and occupational functioning, which further supports this diagnosis.
Generalized Anxiety Disorder (GAD): This is a mental disorder that is characterized by a patient presenting with pervasive anxiety, concentration difficulties, irritability, and lack of sleep (Terlizzi and Villarroel 2020). If the patient’s anxiety was found to be excessive and persistent and lasting for a long period with no specific trigger or stressor, GAD could have been considered as the right diagnosis. His job loss-triggered symptoms make Adjustment Disorder a more likely diagnosis, but GAD remains a consideration if symptoms persist beyond six months.
Major Depressive Disorder (MDD): This is a condition characterized by depressed mood, fatigue, loss of interest in activities, concentration difficulties, and sleeping disturbances. With MDD, patients also face mental challenges such as loss of appetite, anhedonia, feelings of sadness, hopelessness, and worthlessness (Gutiérrez-Rojas et al.,2020). In MDD, the symptoms must be severe and pervasive enough with no specific cause. As such, his recent stressors are suggestive of adjustment disorder.
Reflections:
I agree with my preceptor’s assessment and diagnostic impression of Adjustment Disorder for the patient. The symptoms triggered by job loss and its implications on his daily functioning are well aligned with the diagnosis. The temporal relationship between the stressor and symptom onset supports the diagnosis of Adjustment Disorder rather than Major Depressive Disorder or Generalized Anxiety Disorder. From this case, I learned the need for a thorough biopsychosocial assessment to accurately identify the underlying causes of a patient’s symptoms. Understanding the patient’s context, such as recent job loss, is crucial in forming a correct diagnosis and creating an effective treatment plan. I would ensure continuous patient progress monitoring, potentially incorporating regular standardized assessment tools to objectively measure symptom changes.
Additionally, I might explore offering group therapy sessions for individuals experiencing job-related stress, providing them with additional social support. I will ensure the patient receives unbiased and non-discriminatory care, regardless of his employment status. It is also essential to respect his autonomy in treatment decisions, including any preferences he may have regarding therapy or medication. The patient’s social life and economic status have significantly been affected by his job loss. Providing him with job search resources and financial counseling will help him manage some of his stress. Considering the patient’s family history of depression and his current status of joblessness, it is beneficial to promote mental health awareness and coping strategies. It will be important to ensure that the patient’s therapy is culturally sensitive and that any health promotion strategy is relevant to his lifestyle and preferences.
Case Formulation and Treatment Plan:
It is important to explore the diagnostics that need to be obtained. This plan will include Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and Thyroid Function Tests (TFTs) to rule out any underlying medical conditions that might contribute to her symptoms. Standardized tools like the Beck Depression Inventory (BDI) and the Generalized Anxiety Disorder 7 (GAD-7) scale should be used to quantify the severity of the symptoms and monitor progress( Ramamurthy et al., 2022). The patient does not need a referral at this point. He will also need a career counselor to assist him with job search and career planning as well as help him address the primary stressor contributing to his adjustment disorder. The patient should was started on weekly CBT sessions to help him challenge his negative thought patterns, develop coping patterns, and engage in behavioral activations. For the adjustment disorder, the patient should Start Sertraline 25 mg once a day and increase it gradually as tolerated to target both anxiety and depressive symptoms(Zapata- Ospina.,2023). Provide education about the nature of his condition, typical symptoms, causes, and prognosis. Schedule a follow-up visit in 2 weeks to assess the patient’s response to treatment, symptom progression, and medication tolerance (Ramamurthy et al., 2021). Review the results of any diagnostic studies performed.
PRECEPTOR VERIFICATION:
I confirm the patient used for this assignment is a patient seen and managed by the student at their Meditrek-approved clinical site during this quarter’s course of learning.
References
Gutiérrez-Rojas, L., Porras-Segovia, A., Dunne, H., Andrade-González, N., & Cervilla, J. A. (2020). Prevalence and correlates of major depressive disorder: a systematic review. Brazilian Journal of Psychiatry, 42, 657-672. https://doi.org/10.1590/1516-4446-2020-0650.
Kazlauskas, E., & Quero, S. (2020). Adjustment and coronavirus: How to prepare for COVID-19 pandemic-related adjustment disorder worldwide? Psychological Trauma: Theory, Research, Practice, and Policy, 12(S1), S22. https://psycnet.apa.org/doi/10.1037/tra0000706.
Ramamurthy, P., Alexander, A., Solomon, S., & Thilakan, P. (2022). Prescription pattern and follow-up pattern in psychiatric outpatients with adjustment disorder. Indian Journal of Psychological Medicine, 44(5), 530-531. https://doi.org/10.1177/02537176211015098.
Terlizzi, E. P., & Villarroel, M. A. (2020). Symptoms of generalized anxiety disorder among adults: United States, 2019.
Winter, L., Naumann, F., Olsson, K., Fuge, J., Hoeper, M. M., & Kahl, K. G. (2020). Metacognitive therapy for adjustment disorder in a patient with newly diagnosed pulmonary arterial hypertension: a case report. Frontiers in Psychology, 11, 143. https://doi.org/10.3389/fpsyg.2020.00143.
Zapata-Ospina, J. P., Jiménez-Benítez, M., & Fierro, M. (2023). “I was very sad, but not depressed”: phenomenological differences between adjustment disorder and a major depressive episode. Frontiers in Psychiatry, 14, 1291659. https://doi.org/10.3389/fpsyt.2023.1291659.
PRAC 6665 Week 3 Assignment: Focused SOAP Note and Patient Case Presentation
Week 3: Focused SOAP Note and Patient Case Presentation
| What do I have to do? | When do I have to do it? |
| Review your Learning Resources. | Days 1–7 |
| Assignment 1: Clinical Hour and Patient Logs | Record your clinical hours and patient encounters in Meditrek by Day 7. |
| Assignment 2: Focused SOAP Note and Patient Case Presentation | Submit by Day 7. |
Introduction
Consider the experiences you have had thus far, either in the healthcare workplace or at your practicum site. As you likely know, a nurse’s job does not begin and end with one-to-one patient contact. It includes meetings, documentation, trainings, and collaboration. In particular, the nurse is a member of an interdisciplinary team and must use oral and written communication to inform others of a patient’s status. A central skill of advanced practice nursing, then, is the ability to present a patient’s history, symptoms, diagnosis, and treatment plan to relevant parties involved in treatment.
This week, in addition to your Meditrek tracking, you will develop a focused SOAP note and video case presentation on one of the patients you have examined in your clinical practicum.
Learning Objectives
Students will:
- Describe clinical hours and patient encounters
- Assess patients across the lifespan in mental health settings
PRAC 6665 Week 3 Assignment Focused SOAP Note and Patient Case Presentation - Formulate differential diagnoses for patients across the lifespan in mental health settings
- Develop plans of care for patients across the lifespan in mental health settings
- Advocate health promotion and patient education strategies across the lifespan
- Develop a case study presentation based on a clinical patient
Learning Resources
Required Readings (click to expand/reduce)
Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
- Section II. The Psychiatric History (Chapters 14–18)
- Section III. Interviewing for Diagnosis: The Psychiatric Review of Symptoms (Chapters 23–24)
Document: Focused SOAP Note Template (Word document)
Document: Focused SOAP Note Exemplar (Word document)
Name: Assignment Rubric
| Excellent | Good | Fair | Poor | |||
| Summarize your interpretation of the frequency data provided in the output for respondent’s age, highest school grade completed, and family income from prior month. | 32 (32%) – 35 (35%)
The response accurately and clearly explains, in detail, a summary of the frequency distributions for the variables presented. The response accurately and clearly explains, in detail, the number of times the value occurs in the data. The response accurately and clearly explains, in detail, the appearance of the data, the range of data values, and an explanation of extreme values in describing intervals that sufficiently provides an analysis that fully supports the categorization of each variable value. The response includes relevant, specific, and appropriate examples that fully support the explanations provided for each of the areas described. |
28 (28%) – 31 (31%)
The response accurately summarizes the frequency distributions for the variables presented. The response accurately explains the number of times the value occurs in the data. The response accurately explains the appearance of the data, the range of data values, and explains extreme values in describing intervals that provides an analysis which supports the categorization of each variable value. The response includes relevant, specific, and accurate examples that support the explanations provided for each of the areas described. |
25 (25%) – 27 (27%)
The response inaccurately or vaguely summarizes the frequency distributions for the variables presented. The response inaccurately or vaguely explains the number of times the value occurs in the data. The response inaccurately or vaguely explains the appearance of the data, the range of data values, and inaccurately or vaguely explains extreme values. An analysis that may support the categorization of each variable value is inaccurate or vague. The response includes inaccurate and irrelevant examples that may support the explanations provided for each of the areas described. |
0 (0%) – 24 (24%)
The response inaccurately and vaguely summarizes the frequency distributions for the variables presented, or it is missing. The response inaccurately and vaguely explains the number of times the value occurs in the data, or it is missing. The response inaccurately and vaguely explains the appearance of the data, the range of data values, and an explanation of extreme values, or it is missing. An analysis that does not support the categorization of each variable values is provided, or it is missing. The response includes inaccurate and vague examples that do not support the explanations provided for each of the areas described, or it is missing. |
||
| Summarize your interpretation of the descriptive statistics provided in the output for respondent’s age, highest school grade completed, race and ethnicity, currently employed, and family income from prior month. | 45 (45%) – 50 (50%)
The response accurately and clearly summarizes in detail the interpretation of the descriptive statistics provided. The response accurately and clearly evaluates in detail each of the variables presented, including an accurate and complete description of the sample size, the mean, the median, standard deviation, and the size and spread of the data. |
40 (40%) – 44 (44%)
The response accurately summarizes the interpretation of the descriptive statistics provided. The response accurately explains evaluates each of the variables presented, including an accurate description of the sample size, the mean, the median, standard deviation, and the size and spread of the data. |
35 (35%) – 39 (39%)
The response inaccurately or vaguely summarizes the interpretation of the descriptive statistics provided. The response inaccurately or vaguely evaluates each of the variables presented, including an inaccurate or vague description of the sample size, the mean, the median, the standard deviation, and the size and spread of the data. |
0 (0%) – 34 (34%)
The response inaccurately and vaguely summarizes the interpretation of the descriptive statistics provided, or it is missing. The response inaccurately and vaguely evaluates each of the variables presented, including an inaccurate and vague description of the sample size, the mean, the median, the standard deviation, and the size and spread of the data, or it is missing. |
||
| Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction is provided which delineates all required criteria. |
5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion is provided which delineates all required criteria. |
4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment is stated, yet is brief and not descriptive. |
3 (3%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment is vague or off topic. |
0 (0%) – 2 (2%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion was provided. |
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| Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation |
5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors. |
4 (4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors. |
3 (3%) – 3 (3%)
Contains several (3 or 4) grammar, spelling, and punctuation errors. |
0 (0%) – 2 (2%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding. |
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| Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list. | 5 (5%) – 5 (5%)
Uses correct APA format with no errors. |
4 (4%) – 4 (4%)
Contains a few (1 or 2) APA format errors. |
3 (3%) – 3 (3%)
Contains several (3 or 4) APA format errors. |
0 (0%) – 2 (2%)
Contains many (≥ 5) APA format errors. |
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| Total Points: 100 | ||||||
Name: Assignment Rubric