SHERMAN TREMAINE Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders

SHERMAN TREMAINE Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders

Name: SHERMAN TREMAINE

DOB: November 3, 1968

Sex: Male

Race: African American

Subjective:

CC (chief complaint): ‘’Well, my sister made me come in. I was living with my mom, and she died. I was living and not bothering anyone, and those people– those people, they won’t leave me alone.’’

HPI: A 54-year-old male walked into the clinic on an appointment for an evaluation patient states that his sister advised him to see the doctor. According to the patient, he lived with his Mom until she passed on to glory three years ago. The patient states that he was not bothering anyone, and those people– those people, they won’t leave him alone.’ ’The ones outside his window watching. They watch him, he said. He can hear them and sees their shadows. They think he doesn’t see them, but he says he does. The government sent them to watch me, so my taxes are high in the sky. Do you know that bird? Hear that– hear that heavy metal music? They want you to think it’s weak, but it’s heavy. SHERMAN stated that this started for weeks, weeks, and weeks and weeks, affecting his sleep. The voices are loud and keep him up for days and days. He said that he tries to watch TV, but they watch him through the screen, and they come in and poison his food. He said that he tricked them, though, and locked everything up in the fridge. They aren’t getting in there.

Past psychiatric history• Hospitalized three times at age 20 for an unspecified mood disorder.

Medication trials and current medications• Takes metformin for diabetes. Tried Haldol, Thorazine,  Risperidone, and  Seroquel.( All discontinued)

Psychotherapy or previous psychiatric diagnosis• No history of prior psychotherapy but had three hospital admissions at age 20.

Substance Current Use:  SHERMAN states that he smokes about three packs of cigarettes daily and smokes all day.  SHERMAN drinks about 12 packs back alcohol weekly, with the last drink being yesterday. The history of marijuana and previous use three was three years. The patient denies using cocaine.

Family psychiatric/substance use: Dad was crazy with paranoid schizophrenia. Mom had anxiety. Dad drank alcohol and had a history of Marijuana when mom was alive. Dad was hospitalized in the old state hospital.

BUY A SOAP NOTE HERE

Social: Raised by my mom and my sister, he currently lives with his sister. Never been married, have no children, my highest level of education is 10
th
grade, I smoke (Three packs a day.), live with my mom, and she died, drink alcohol about 12 packs a week. Denies DUIs or legal issues from drugs or alcohol. Does not go to the grocery store. History of marijuana three years ago when mother was alive. Prohibits use of any cocaine, Deniny blackouts or seizures or ,see or hearing things from drugs or alcohol. No history of family members or relatives committing suicide. It does not work, so smoking and drinks pop stuff he does for fun. He denies ever being arrested orconvicted for anything legally but was warned to quit calling 911 about the people outside. SHERMAN confirmed childhood trauma/abuse from his dad when he was alive.

 

Medical: History: diabetes, fatty liver

Allergies: No history of any allergies.

Reproductive Hx
: History of gynecomastia (boobs) side effect from Risperidone, denies sexual history or abuse

ROS:

GENERAL
: well-groomed for the season, no weight loss, no distress, and no hotness of body.

HEENT:
No vision problem. Ears normal shape with no discharges. Nose normal shape; no bleeding or septal deviation or drainage. No sore throat or swelling around the neck.

SKIN: Skin intact and appropriate; no rash or lesion noted

CARDIOVASCULAR: no cardiovascular abnormality

RESPIRATORY: Lungs sound clear, and no adventitious lung sound

GASTROINTESTINAL: All bowel sounds on all four quadrants

GENITOURINARY: No disorder or problem with this system

NEUROLOGICAL: alert and oriented to person, place, time, and situation but easily distracted.

MUSCULOSKELETAL: All extremities are moveable; some tremors noted in upper extremities

HEMATOLOGIC: No bleeding or purpura

LYMPHATICS: No swollen lymph nodes

ENDOCRINOLOGIC: controlled diabetes type 2

Objective
:

 Physical exam:

Vital signs:
Obtained and recorded

Weight= Height = BMI
=( obtained and recorded)

Diagnostic results,
including any labs and imaging: No diagnostic test is ordered or required at this time

Assessment:

Mental Status Examination:

A 54-year-old male, alert and oriented, appears to be a stated age. The patient was groomed for the weather and well-nourished. The patient remained cooperative with the assessment and answered questions without fidgeting. He is a good historian and maintained good eye contact with occasional distractibility. The patient appeared anxious, coherent, illogical, and slightly frightened. The patient was seated upright without any excess abnormal body movement. Noted patient with a constricted flat affect, no acute psychosis documented. The patient had audio-visual hallucinations and was responding to internal stimuli. He was paranoid, delusional, and intrusive without insight into his mental health. Denies suicidal or homicidal ideations. Speech is clear, of average volume and pitch, with no echolalia. The patient could recall past and present memories with mild forgetfulness, as he could not state the date.

Diagnostic Impression:

Schizophrenia Paranoid type.

The patient’s primary diagnosis is Schizophrenia. Schizophrenia is a mental illness of unknown etiology characterized by the person’s inability to think, feel or behave appropriately. It is associated with alteration in brain function, and It is believed that Schizophrenia has both genetic and environmental factors that play a role in its cause. It is also described as psychosis, and the sufferer loses touch with reality. To be diagnosed with schizophrenia, according to DSM-5, specific criteria must be met, including delusions, hallucinations, and disorganized speech or thoughts. There are negative symptoms such as paranoid or catatonic behavior, all lasting at least six months. The patient in this scenario, Mr. S T, presented with paranoid behavior, evidenced by the fact that he said the government was after him. He was also delusional and heard voices as he asked the clinician if she heard or could see them from the window; three hospitalizations evidenced the duration and symptoms over six months at the age of 20 years.

Schizoaffective Disorder:
This chronic, relatively rare mental health disorder occurs prevalence in only 0.3% of the population. It affects males as much as females, with early onset in males than in females. It manifests with schizophrenic symptoms such as hallucinations or delusion and symptoms of mood disorders such as mania and depression. Its etiology is unknown; however, some schools of thought link it to genetics, brain chemistry and structure alteration, extreme stress, and substance abuse such as psychoactive drugs like LSD. Schizoaffective disorder poses significant challenges with the diagnosis because of conflicting or overlapping symptoms of schizophrenia and either depression or bipolar disorder. It is classified as schizo-affective disorder bipolar or depressive type, and close monitoring is essential as signs are based on the style. This condition is ruled out in Mr. ST because he did not show any depressive symptoms. To diagnose a patient with schizo- affective disorder, a major mood disorder, either depression or mania, occurs at the same time that symptoms of schizophrenia are present with delusions or hallucinations for two or more weeks in the absence of a major mood episode(DSM-5)

Delusion of Persecution
: Delusion is a fictitious belief that is baseless to the observer but is meaningful to the person. The content of the idea to the thinker is that of doom, mishap, and problem. While the onlooker or observer cannot see this, the person involved is overwhelmed by the thoughts. It is a baseless belief that does not correlate with the person’s level of education, intelligence, or cultural background. The person suffering from delusion has a solid grip on his belief despite apparent reasons not to believe it. In the delusion of persecution, the person feels ill-treated, hunted by authorities, and constantly makes phone calls to authorities to report the baseless allegations. Criteria for diagnosis, according to DSM-5, include delusion for at least one month, an unfounded phobia that impacts a person’s daily activities, hallucinations associated with the delusions, frequent reporting to authorities, and irresistible feeling of threat without reason. The patient in this scenario met all these criteria. SHERMAN TREMAINE Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders

Reflections:

Accurate diagnosis, planning, and treatment of a  patient start with comprehensive data collection or patient histories. This includes past and present medical/surgical, psychiatric, family, and social accounts. It also includes records of past and current substance use/ abuse, hospitalizations, support system, and medical and behavioral assessments. Building trust and communication starts from the first encounter as the patient walks into the clinic. Recognizing that patients living with mental are often disrespected and taken advantage of, it is vital to integrate the patient’s culture and beliefs into his care. Analyzing this case scenario as an NP, I would do a few things differently.

Case Formulation and Treatment Plan
: Psychosocial treatments enable people to compensate for or eliminate the barriers caused by their schizophrenia and learn to live successfully. If a person participates in psychosocial rehabilitation, she is likelier to continue taking their medication and less likely to relapse. Schizophrenia is treated with antipsychotics together with other medications and psychotherapy. Mr. ST had been introduced to Haldol, Thorazine, Risperidone, and Seroquel; however, he exhibited non-compliance syndrome. Some factors contributing to ST’s relapse include substance, lack of insight, and lousy habit of taking medications. Patients and caregivers should be educated on the need to keep treatment regimens, monitor medication side effects, and sign in for drug rehabilitation.

In the Plan section, provide:•

Plan for psychotherapy•

Cognitive behavioral therapy (CBT) is one of the psychotherapy plans I will recommend for Mr. ST. This therapy will help identify and address negative thoughts, which will change unwanted behavior patterns. It will equally offer the opportunity for family and group participation which builds support for the patient. Otherwise known as a talk show, it provides a safe space to discuss ways the patient can manage the symptoms. The use of psychotherapy in treating patients is based on regular personal interactions to help the person change their behavior, increase happiness, and overcome problems. If psychotherapy is to be effective, the patient’s motivation is crucial. Mental health affects the individual as much as it affects families, loved ones, and caregivers.

Alternative therapies.
Supplements like  Fish oil, Rhodiola Rosea., S-adenosylmethione, N-acetylcysteine., Choline, and Inositol. St. John’s wort and Calming techniques have not been scientifically proven; they can be used; however, they should not replace the provider’s orders. The patient should verify with the provider before using them to avoid an adverse reaction.

Pharmacologic and Nonpharmacologic treatments:

The best treatment for schizophrenia is a combination of medication, psychological therapy, and community support. Antipsychotics, Mood stabilizer antiepileptics, and antidepressant-antipsychotics. Never give an SSRI alone to a manic patient because of the fear of flipping over the euthymic level into the manic state.

 

Follow-up parameters as well as a rationale for this treatment and management plan.

Since schizophrenia has public health implications and its pathomechanism is not fully understood, follow-up must be ongoing.  Severe limitations characterize antipsychotics, with treatment being efficient for about half of the patients, depending on the group of symptoms presenting, positive, negative, and cognitive. Due to the interactions of antipsychotics with various neurotransmitter receptors, severe neurological and metabolic side effects may lead to sexual dysfunction or agranulocytosis, e.g. (clozapine); close monitoring is essential.

Incorporate one health promotion activity and one patient education strategy.

Interpersonal and social rhythm therapy that synchronizes the patient’s daily habits and activities, such as sleeping, eating, and exercise, is one health promotion activity I will recommend for ST. Embracing this health promotion and incorporating them efficiently into her daily activities could help her have fewer mood swings and less severe outcomes. Integrating Psychoeducational into the treatment of Mr ST is essential as it will help him and his support system learn about his circumstance and their management by identifying early mood signs and handling them timely.

Discussion includes what may be done differently with this patient if the student conducted the session agai
n.

The debilitating nature of schizophrenia and the involvement of three groups of positive, negative, and cognitive symptoms make its treatment and patient compliance challenging. As an NP, I am also the patient advocate. I will validate the reason for the patient’s non-compliance with the prior prescriptions, making sure that he does not have problem with  affordability. I may suggest approval for a long-acting injectable for ST if he has issues taking his medications daily.

Legal/ethical considerations:

According to healthy people 2020, neighborhood/environment, economic stability, education, social and community context, health, and healthcare are significant determinants of health. Living in a high-density public housing complex or poor neighborhood with poor access to social amenities and good healthcare could have contributed to Mr ST’s.  constant relapse. Disease and infections associated with overcrowding, environmental pollution, airborne diseases, poor nutrition with malnutrition complications, water contamination resulting in waterborne diseases, violence, bullying, drug abuse, and sex trafficking are some risks Mr.ST can face. Assessing his .  ability to afford his medications, does he have a provider? What legislature is impacting his zip code? Does he have resources for community support? Can he afford his prescriptions? The practitioner is legally and ethically obligated to advocate for her patients. It is ethical to maintain a therapeutic alliance and the responsibilities of both the therapist and the participants when referred to psychotherapy. In psychiatry, ethical issues are viewed differently from other medical disciplines because of the vulnerability of these groups and the stigma associated with mental illness. Issues related to informed consent, confidentiality, conflict of interest, therapeutic misconception, placebo-related, vulnerability, exploitation, and operational challenges are some SHERMAN TREMAINE Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders

 

References

McCutcheon, R., Reis Marques, T., & Howes, O. (2020). Schizophrenia—An Overview. JAMA

Psychiatry, 77(2), 201. https://doi.org/10.1001/jamapsychiatry.2019.3360

Stępnicki, P., Kondej, M., & Kaczor, A. (2018). Current Concepts and Treatments of Schizophrenia.

Molecules, 23(8), 2087. https://doi.org/10.3390/molecules23082087

American Psychiatric Association. (2013).
Diagnostic and Statistical Manual of Mental

Disorders,
fifth edition DSM-5 American Psychiatric Association, 2013.

Bachem, R., & Casey, P. (2018). Schizoaffective Disorder: A diagnosis whose time has come.

Journal of Affective Disorders
,
227
, 243-253. https://doi.org/10.1016/j.jad.2017.10.034

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2014).
Kaplan and Sadock’s synopsis of psychiatry:

Behavioral sciences/clinical psychiatry (11th ed.).
Philadelphia, PA: Wolters Kluwer

PsychScene Hub. (2017, April 24). Movement disorders with antipsychotic medication linked to an external site.- Conversations with Dr. Stephen Stahl [Video]. YouTube.

PsychScene Hub. (2017, April 24). Movement disorders with antipsychotic medication Links to an external site.- Conversations with Dr. Stephen Stahl [Video]. YouTube. https://www.youtube.com/watch?v=ipW5AcbFzzE

Vallejo, E. (2020). Realistic schizophrenia simulation Links to an external site. [Video]. YouTube. https://www.youtube.com/watch?v=63lHuGMbscU

Walden University. (2021). Case study: Sherman Tremaine. Walden University Canvas. https://waldenu.instructure.com

Vallejo, E. (2020). Realistic schizophrenia simulation links to an external site. [Video]. YouTube. https://www.youtube.com/watch?v=63lHuGMbscU

Walden University. (2021). Case study: Sherman Tremaine. Walden University Canvas. https://waldenu.instructure.com SHERMAN TREMAINE Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders

 

Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders

Psychotic disorders change one’s sense of reality and cause abnormal thinking and perception. Patients presenting with psychotic disorders may suffer from delusions or hallucinations or may display negative symptoms such as lack of emotion or withdraw from social situations or relationships. Symptoms of medication-induced movement disorders can be mild or lethal and can include, for example, tremors, dystonic reactions, or serotonin syndrome.

For this Assignment, you will complete a focused SOAP note for a patient in a case study who has either a schizophrenia spectrum, other psychotic, or medication-induced movement disorder.

Resources

 

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

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: Sherman Tremaine
. 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.

Consider what history would be necessary to collect from this patient.

Consider what interview questions you would need to ask this patient.

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 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 the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, and list them in order from highest priority to lowest priority. Compare the 
DSM-5-TR
 diagnostic criteria for each differential diagnosis and explain what 
DSM-5-TR
 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:
 What would you do differently with this patient if you could conduct the session again? Discuss what your next intervention would be if you were able to follow up with this patient. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion, and disease prevention, taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

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).

By Day 7 of Week 5

Submit 
your Focused SOAP Note.

 

submission information

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the 
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 from the 
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Then, click on 
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Rubric

NRNP_6675_Week5_Assignment_Rubric

NRNP_6675_Week5_Assignment_Rubric

Criteria

Ratings

Pts

This criterion is linked to a Learning Outcome
Create documentation in the Focused SOAP Note Template about your assigned patient.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 90%–100%
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 80%–89%
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 70%–79%
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 0%–69%
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:• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses

SHERMAN TREMAINE Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders

15
 
to >
13.0
 pts
Excellent 90%–100%
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.

13
 
to >
11.0
 pts
Good 80%–89%
The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.

11
 
to >
10.0
 pts
Fair 70%–79%
Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.

10
 
to >
0
 pts
Poor 0%–69%
The response provides incomplete or inaccurate documentation of the patient’s physical exam. 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 90%–100%
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 80%–89%
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 70%–79%
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 0%–69%
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 90%–100%
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 80%–89%
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 70%–79%
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 0%–69%
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
• Discussion include what may be done differently with this patient if student conducted the session again. Discussed the next intervention if you could follow up with this patient. The discussion was related to legal/ethical considerations (demonstrated critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention that take 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 90%–100%
Reflections are thorough, thoughtful, and demonstrate critical thinking. Reflections contain a discussion of all elements described within assignment directions.

4
 
to >
3.5
 pts
Good 80%–89%
Reflections demonstrate critical thinking. Reflections contain 2 out of 3 (legal/ethical considerations, social determinate of health, health promotion) with consideration of patient factors and risk factors.

3.5
 
to >
3.0
 pts
Fair 70%–79%
Reflections are somewhat general or do not demonstrate critical thinking. Reflections contain 2 out of 3 (legal/ethical considerations, social determinate of health, health promotion) without consideration of patient factors and risk factors.

3
 
to >
0
 pts
Poor 0%–69%
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 90%–100%
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 80%–89%
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 70%–79%
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 0%–69%
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 90%–100%
Uses correct APA format with no errors

4
 
to >
3.5
 pts
Good 80%–89%
Contains 1-2 APA format for parenthetical/in-text citations and reference list errors

3.5
 
to >
3.0
 pts
Fair 70%–79%
Contains 3-4 APA format for parenthetical/in-text citations and reference list errors

3
 
to >
0
 pts
Poor 0%–69%
Contains five or more APA format for parenthetical/in-text citations and reference list errors

5
 pts

This criterion is linked to a Learning Outcome
Written Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and punctuation

SHERMAN TREMAINE Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders

5
 
to >
4.0
 pts
Excellent 90%–100%
Uses correct grammar, spelling, and punctuation with no errors

4
 
to >
3.5
 pts
Good 80%–89%
Contains 1-2 grammar, spelling, and punctuation format errors

3.5
 
to >
3.0
 pts
Fair 70%–79%
Contains 3-4 grammar, spelling, and punctuation format errors

3
 
to >
0
 pts
Poor 0%–69%
Contains five or more grammar, spelling, and punctuation format errors that interfere with the reader’s understanding

5
 pts

Total Points: 
100