Posted: September 19th, 2022

Week 3: Focused SOAP Note and Patient Case Presentation

 

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. 

To Prepare

Overview

Early childhood educators are responsible for selecting safe and developmentally
appropriate toys for children of various age groups and stages of development. For toys
to be developmentally appropriate, the toys and materials used to make them must
meet the needs of children at a particular age and stage of development. When you’re
an early childhood educator, you’ll need to know what is both safe and developmentally
appropriate for the children for whom you’re buying toys. You should consider the
individual needs of each child who will use the toys.

Instructions

Research the guidelines for selecting safe and developmentally appropriate toys for all
children ages birth to eight years. Then, select three specific toys you believe to be safe
and developmentally appropriate for children of a selected age group, and explain the
appropriateness of the toy as you answer a series of questions about each toy.

You’ll provide all of the requested information and answer all of the questions.

Part 1

Research the appropriate guidelines for selecting toys for young children. This
information is available on the Internet and in many early childhood publications. Then,
write a short essay of 300-350 words summarizing many guidelines regarding toy safety
and developmental appropriateness. You’ll likely wish to include at least fifteen
guidelines in your essay.

In your essay, you must include in-text citations in APA format to indicate where the
information originated from. Utilize available resources in your course

(Links to an external site.)

if you are unfamiliar with how to correctly cite your research in-text and at the close of
your paper.

Essays received without proper in-text citations and a References page in APA format
will be considered plagiarized, and the student will penalized according to EGCC’s
Teacher Education Department’s Academic Integrity Policy. Ensure you are correctly
citing all of your research in your essay.

https://extras.apa.org/apastyle/basics-7e/?_ga=2.226844699.768727431.1599234532-820941257.1598624727#/lessons/cn3Cb6ANDrUSP9p-iF74eaXCwYJfJJV-

https://extras.apa.org/apastyle/basics-7e/?_ga=2.226844699.768727431.1599234532-820941257.1598624727#/lessons/cn3Cb6ANDrUSP9p-iF74eaXCwYJfJJV-

Part 2

Select one of the following age groups:

○ 6 to 12 months
○ 1 to 3 years
○ 3 to 5 years

Select three toys you believe to be safe, developmentally appropriate and educational
for a typical child within the age group you’ve selected. For each of the toys, provide
responses to the following questions using fully developed sentences and paragraphs:

○ Provide the full name of the toy, and the name of the manufacturer.
You must also include an image of the toy.

○ Provide a detailed description of the toy in your own words. Use
5-7 sentences to indicate, for example, the size of the toy, the
materials it’s made from, it’s purpose, how it is cleaned and
sanitized, how it is played with, how it is stored, its typical purchase
price and where it can be purchased, and other information you
wish to share.

Then, answer each of these questions, in at least two fully-developed paragraphs:

1. Why is this toy developmentally appropriate for a child in this age
group?

2. Why is this toy educational? What can children learn by playing
with this toy?

3. Why is this toy appealing to a child in this age group?
4. Would a parent select this toy? Why or why not?
5. Would you select this toy to use with a child in this age group? Why

or why not?
6. Is the toy safe for young children? Why or why not?
7. What hazards could you anticipate with this toy? How can you

prevent the hazard from happening?

Writing Guidelines

1. Type your submission, double-spaced, in a standard print font, size 12. Use a
standard document format with one-inch margins. (Times New Roman or
Arial are recommended fonts.)

2. Include a Title Page in APA format to include your full name, the name of this
project, the name and number of this course, and the date. You are not
required to have a running header for this assignment.

3. Read the assignment carefully, and include all of the necessary information.
Be sure to cite all of the websites and articles you use.

4. Include in-text citations in your essay, and a References page; use APA
format for both.

Prior to Submission, ensure that you have:

● Provided clear answers to the assigned questions
● Addressed the questions in complete sentences, not just simple yes or no

statements
● Supported your opinion by citing specific information from credible information

you found online
● Focused on the assigned issues
● Written an essay in Part One with a minimum of 300-350 words, and have

fully responded to the 7 guiding questions, regarding the toys safety and
developmental appropriateness for the child, in Part Two.

● Completed your own work and are not submitting someone else’s work
● Correctly cited your research in-text and at the close of your paper in APA

format
● Used correct grammar, spelling, punctuation, and sentence structure

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Week (enter week #): (Enter assignment title)

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6665: PMHNP Care Across the Lifespan I

Faculty Name

Assignment Due Date

Subjective:

CC (chief complaint):

HPI:

Substance Current Use:

Medical History:

·
Current Medications:

·
Allergies:

·
Reproductive Hx:

ROS:

· GENERAL:

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:

Diagnostic Impression:

Reflections:

Case Formulation and Treatment Plan: 

References

© 2021 Walden University

Page 1 of 3

Case study

Chief complaint. I feel overwhelmed, anxious, mood swing and unable to sleep for a week’

HPI. K is 36 years old AA female who presented to the clinic for follow up appointment, history of PTSD depression and anxiety. Kimberly stated that she has been down for about a week now, has not been answering her phone, sad mood. she stated that she has not picked up her medications because she does not want to take any medication and has not seen her therapist. Patient report continuous high level of stress since grandmother moved to hospice care. Report biological mother died last year and was raised by grandmother due to been physical abused by biological mother, Reports was molested by her cousin, stated I hated and dislike my mother and I do have nightmares about her. Patient reports sometimes she gets chest tightness and feeling of impending doom and runs for cover sometimes. She reports feeling depressed and lack of motivation and lack of sleep sometimes, reports she stays awake at night thinking about her grandmother. She reports a difficulty relationship with her boyfriend. She lives with her boyfriend and her two young children 5-year-old, 3-year-old. She works as an animal caretaker and currently on disability due to finger injury. Sister has depression, mother bipolar. K denies legal issues, denies suicidal intentions or ideation, denies homicidal ideation and intention, denies seeing things or hearing voices.

Allergies: No known drug allegations

Current medication Citalopram 20 mg by mouth daily Hydroxyzine HCI 25 mg by mouth twice daily as needed.

Medical history: COPD Hypertension

Mental Status Exam. She is alert and oriented to person, time, place, and situation. Her speech is clear and normal in tone. Her mood appears to be depressed and affect congruent to her mood. She denies visual or auditory hallucinations. No signs of delusional or elevated mood noted.

Assignment : Focused SOAP Note and Patient Case Presentation

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.

To Prepare

Create a Focused SOAP Note on this patient using the template provided in the Learning Resources..

Please Note:

When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor.

Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.

Ensure that you have the appropriate lighting and equipment to record the presentation.

The Assignment

. 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.

Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.

Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.

Subjective: What details did the patient provide regarding their chief complaint and symptomology 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 their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis and why?
Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.

Plan: In your video, describe your treatment plan using clinical practice guidelines supported by evidence-based practice
. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session?

In your written plan include all the above as well as include one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.

Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.

Submit your Video and Focused SOAP Note Assignment. You must submit two files for the note, including a Word document and scanned pdf/images of each page that is initialed and signed by your Preceptor.

Please address the highlights and add four references. Thanks

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