Each week students will choose one patient encounter to submit a Follow-up SOAP note for review.
Follow the rubric to develop your SOAP notes for this term.
The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.
Initial Psychiatric Interview/SOAP Note Template
|Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion)
DOB: 67years old (specifice date not provided).
Gender Identifier Note:Male
CC: “I hear voices in my head telling me to do bad things, and I have trouble distinguishing what’s real and what’s not. I also feel very sad and hopeless most of the time, and I’ve lost interest in things I used to enjoy”.
HPI: Willie a 67years old male presents with a history of auditory hallucinations and delusions. He reports hearing multiple voices in his head that tell him to harm himself and others. He also has difficulty distinguishing these voices from reality. Additionally, he reports feeling sad and hopeless most of the time, with decreased appetite and difficulty sleeping. He also reports to have lost interest in activities he previously enjoyed. The patient has been previously diagnosed with schizophrenia and pschizoaffective disorder, but his symptoms have not improved with previous treatment. The patient’s symptoms have been present all along and have gradually worsened over the time
Patient has been hallucinating. The patient has nomal thought process.
SI/ HI/ AV: patient shows signs of suicidal ideation.
Past Medical Hx: adherence
Past Psychiatric Hx:
Describes stable course of illness.
History of Violence t
Mental health treatment history discussed:
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