Focused SOAP Note for Anxiety, PTSD, and OCD – NRNP-6675 Week 3: Assignment

Focused SOAP Note for Anxiety, PTSD, and OCD – NRNP-6675 Week 3: Assignment

Patient’s name
: DEV CORDOBA

DOB
: 2016

Age
: 7 years

Race
: Caucasian

Sex
: male

Subjective:

Chief complaint(cc):
My Mom thought you would help me improve my mood.

History of present illness (HPI
): The patient is a seven-year-old Caucasian male accompanied by his mother to the clinic. The patient and his mom state that the patient was referred to see the psychiatrist by his pediatrician for evaluation of worrying behavior over his mother and baby brother disappearing like his father. The patient and mother revealed that the patient has been having uncontrollable worries, anxious feelings, and stormy night dreams. It appears to have started after DEV’s father left home for military deployment when DEV was five and he died on active duty. The mother states that she underestimated DEV’s ability to comprehend separation and death and regrets not telling DEV the truth. As a result of DEV’s father’s absence, DEV developed the phobia that he might also wake up one morning and lose his mother and brother.  Due to the bad dreams, DEV sleeps with the door open and the light on. DEV states that he is bullied at school and gets in trouble often, and his teacher tells him to focus and stop looking outside the window. DEV says he does not like to go to school, and students pick on him due to his poor hygiene and enuresis. DEV had DDVP prescribed for nighttime bladder incontinence, which did not help him. The patient confirmed sibling rivalry as he thinks his mother gives more attention to his younger brother. At school, DEV had an outburst that resulted in throwing stuff at a student picking on him. He has a difficult time going to sleep and wakes up frequently. The mother states that DEV has a poor appetite and has lost 3 pounds in three weeks. DEV makes somatic complaints to avoid going to school, and Mom blames herself for DEV’s behavioral outcome.

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Past psychiatric history:
No pertinent psychiatric history.

Medication trials and current medications
– DDVP for enuresis ( nighttime bed wetting).

Psychotherapy or previous psychiatric diagnosi
s: There are no pertinent previous psychiatric histories. No inpatient or outpatient care.

Pertinent substance use:
No history of drug use, and no adult at home uses drugs. Focused SOAP Note for Anxiety, PTSD, and OCD – NRNP-6675 Week 3: Assignment

Family psychiatric/substance use:
DEV is the oldest child in a family of two. He lives with his mother,  younger brother, and Sparky, his dog. DEV’s father died on active military duty when DEV was age five. He denies any form of abuse or substance use by anyone in the family. No pertinent psychiatric history in the family and no histories of grandparents were reviewed in this scenario.

Social History:
DEV is a 7-year-old hyperactive male child living with his mother, baby brother, and his dog called, Spanky.  He thinks his brother smells, cries a lot, and gets more attention from their mother. He is easily distracted at school, and his teacher constantly redirects him. DEV is socially isolated as he is bullied at school due to poor sanitation. He does not like going to school for fear of losing his mother and brother when he is not home; however, he enjoys building Legos. DEV is hyperfunctioning and eats less, and has lost three pounds in three weeks.

Allergie
s. No known food, drug, or seasonal allergies were discovered.

Medical
History: Bedwetting (Enuresis
)

Current Medications:
DDVP for bedwetting

Reproductive History:
No history of hernia or undescended testicles; denies sexual abuse.

Objective

General:
A 7-year- old Caucasian male, well-groomed and dressed appropriately for the weather. Alert and oriented x 4 able to answer assessment questions coherently
.
DEV lost three pounds in three weeks; however, he denies fever, chills, weakness, or fatigue.

Vital signs:
BP 100/56, P- 100, T-98.0, R- 20, Spo2-100% in room air, Ht, Wt, BMI ( to be determined) H
EENT: PERRLA, EOMI
-symmetrical chest wall, Carotid artery noted for bruits, jugular vein tmegally Oro-nasopharynx-clear, neck palpated without any nodes or lesions.

SKIN
: Color and integrity intact and elastic, well hydrated, no edema, no lesions, hair evenly distributed and texture normal, nail texture, nail base angle regular, no ingrowing nails, no hammertoes, no cyanosis observed. No changes in sensation or numbness of the skin, tingling or increased sensitivity/hypersensitivity to light touch, no loss of sensation for touch, cold, heat, pain, or loss of position sense.

GENERAL: No fever, chills, weakness, or fatigue. The patient has lost 3 pounds in the last three weeks.

ROS
:

CARDIOVASCULAR
: Heart: RRR, no murmurs, rub or gallop, chest pain, pressure, or discomfort. No palpitations. No edema pulses bilateral pedal.

RESPIRATORY
: Lungs: CTA, chest wall symmetrical,  no SOB or dyspnea. No cough, no sputum.

GASTROINTESTINAL
: Abd: soft, hyperactive bowel sounds, no pain x 4 quarts.

GENITOURINARY
: Not assessed. Pt states there are no issues.

MUSCULOSKELETAL
: symmetric, no atrophy, arthritis, muscle strengths 5/5 in all groups. No rigidity, stiffness, spasticity/spasms, or slowed movements.

NEUROLOGICAL:
Eye: no anisocoria, right and left pupils are equal, no exophthalmos.
CN 11-X11
grossly intact DTR’s intact. No loss of sense of smell. EOM was noted in all fields of gaze. Ear: No organic disease, no signs of infection, no hearing loss. No ptosis and pupillary constriction were observed. Nose: -no nasal mucosa redness or swelling. No Rhinorrhea and congestion.

Mouth-
Teeth normal dentition and mucosa, no upper molar disease noted, no pain on tapping. No upper motor neuron facial weakness was observed, and the face is symmetrical.

HEMATOLOGIC:
No anemia, bleeding, or bruising, no purpura

LYMPHATICS
: No enlarged nodes, no history of splenectomy

ENDOCRINOLOGIC
: No report of sweating, cold, or heat intolerance. No polyuria or polydipsia

Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses

Reviewing the case scenario, DEV did not undergo any diagnostic tests. Still, he will require comprehensive physical examination using self-assessment questionnaires like the Hamilton anxiety scale, Beck anxiety inventory, social phobia anxiety questionnaire, The Generalized Anxiety Disorder 7-Item (GAD-7) Questionnaire, and PHQ 9 as scales to measure the severity of DEV’s anxiety. To rule out organic causes such as pituitary or cerebral tumors, thyroid function tests (TSH), blood glucose level, echocardiography, and toxicology screening, if necessary, can be done. CT scan, X-ray screening, or MRI can also be done if required. Neck ultrasound to rule out pituitary gland tumor.

                                  Mental Status Examination

DEV is alert and oriented to person, place, time, and event and looks the stated age. He makes good eye contact and is anxious and slightly fidgety. He dressed appropriately for the time of year and weather. He denies auditory/visual hallucinations and suicidal/homicidal ideation. DEV is coherent without looseness of associations, no pressure of speech, flight of ideas, or evidence of hallucinations. DEV speaks clearly, and cohesively and maintains average pitch and volume. He is insightful, evidenced by his understanding of his fears and the need for help. DEV’s thought process is goal-directed as he focuses on the fear of losing his mother and brother just like he did to his father. The uncontrollable fear interferes with his ability to go to school, stay and focus. DEV presents with somatic symptoms of stomach ache to keep off from school. DEV suffered traumatic stress due to his father’s absence and death. He is easily distracted and gets redirected by his teacher multiple times while in school, as evidenced by inattentiveness, hyperactivity, and impulsivity (the teacher tells him to sit down all the time, throws books at his classmate, and looks out of the window). DEV exhibits poor sleep quality as he gets regular nightmares resulting in sleeping with the door open and lights on. DEV’s uncontrollable anxiety interferes with his ability to groom himself, as evidenced by poor hygiene, bedwetting, poor appetite, and subsequent loss of 3 pounds in 3 weeks. There is no history of birth injuries, delayed developmental milestones, or any evidence of abnormal motor activities. DEV’s mother states that he worries over irrelevant baseless things such as ‘’I will soon die or my mother and brother could be missing. DEV has full range of affect but constricted, and he feels sad. He has a steady, upright posture and gait. No acute psychosis, mood swings, delusions, or paranoia was noted.

Differential Diagnoses

Generalized Anxiety Disorder

The primary diagnosis for DEV is generalized anxiety disorder. This is an irresistible, uncontrollable fear that interferes with one’s ability to function normally. It is fear channeled towards several events or activities without apparent reason, lasting more than six months. Anxiety can be a good thing as it can alert us to potential dangers or risks acting as a general stress response. It affects children, adolescents, and adults, as they experience worry, fear and terror for no apparent reason, which is in excess compared to the situation. It is a problem when the dread or anxiety associated with it is beyond the familiar feeling of apprehension, affecting the person’s ability to perform activities of daily living. In children with GAD, physical appearance, prior habits, social acceptance, family difficulties, failure to fulfill parents’ expectations, personal abilities, and academic success are all common concerns for parents, teachers, and caregivers. Anxiety disorder is the most common mental illness, impacting at least one-third of adults sometime in their lives. According to DSM-5 diagnostic criteria for GAD, the patient must manifest at least severe anxiety symptoms, including worries of no apparent measure to its cause, affecting the ability to function, lasting for at least six months. The outcome of the uncontrollable anxiety will cause fatigue, poor concentration, restlessness, agitation, sleep disturbance, muscle tension, and poor appetite. In this scenario, DEV developed as an average functioning child until age five, when his father died. The separation/death of his father traumatized him, which is an event and loss in his life that instilled fear in him. The fear of not losing his mother and brother the same way he lost his father triggered the anxiety that affected his focus in school, poor hygiene, somatic symptoms to get off school, poor sleeping habits, poor appetite and weight loss, impulsive behaviors, poor interactions with peers and regressing, which resulted to bedwetting. Using The Generalized Anxiety Disorder 7-Item (GAD-7) Questionnaire as a screening tool that can also be used to monitor patients with generalized anxiety disorder, I will give DEV a GAD-7 of 10 and PHQ -9 of 14 to confirm my primary diagnosis of GAD.

Adjustment Disorder
:

The out-of-proportion stressful feelings following an unexpected traumatic event in a person’s life and the inability to adjust to the situation can trigger multiple behavioral reactions. Traumatic occurrences include the death of a loved one, loss of employment, ill health, empty nest syndrome, going away to school, divorce, and abuse. Naturally, people adjust to stressful situations within a few months of the incident, approximately three months. Adjustment disorder occurs if an individual cannot move on with everyday life after six months of the incident. The stress he feels brings emotional or behavioral reactions that contribute to anxiety and depression. Its manifestations depend on the type of adjustment disorder and differ from individual to individual. There is a feeling of excessive stress which interferes with quality of life, lasting over six months from the date of the trauma. As a stress-related condition, it can be defined as a maladaptive response to recognized psychosocial stressors or life changes characterized by an obsession with the stressor and failure to adapt to the outcome of the incident. Associated symptoms from stress include sadness, hopelessness, frequent crying, worrying or feeling anxious, nervous, jittery, or stressed out, difficulty sleeping, poor appetite, poor concentration, feeling overwhelmed, difficulty with activities of daily living, isolation, avoiding essential things such as going to work, school, or paying bills, and suicidal thoughts or behavior. According to The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), before the criteria for diagnosis is met, three months from the date of the incident must elapse, plus the presence of severe anxiety that is out of proportion with the stressor which will affect the quality of life of the individual and causes pain. Although DEV presented some signs and symptoms in this scenario, I ruled out adjustment disorder because he denied suicidal ideation and no motion of depression, such as excessive crying.

Dysthymic Disorder:
Sadness that occurs more significantly during the day, lasting for more than two years, is pathological.  Often reported by people’s observations or personal accounts, it can present the following symptoms, poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, feelings of hopelessness, and suicide. Depression and anxiety are two distinct diagnostic entities that frequently co-occur due to shared underlying traits. The presence of GAD enhances the possibility of signs of depression manifesting. The difference between GAD and MDE lies in the clusters of symptoms within the tempo-longitudinal pattern. Whereas GAD presents as a heterogeneous disorder with other forms of anxiety, it has less affinity to depression. Classifying GAD with MDE undermines diagnostic comorbidity patterns and minimizes the importance of longitudinal data on risk factors and symptom trajectories. In Dysthymic Disorder, symptoms are not drug-induced or caused by general debility. The criteria for the diagnosis of dysthymic disorder, according to DSM-5, must include at least five signs, with at least a cardinal sign drawn from a sad mood, lack of interest, or pleasure. DEV not wanting to go to school, as he verbalized in the scenario, and he has poor or lack of focus, as expressed by the teacher, are some of the criteria for ruling out this diagnosis.

Plan for treatment and management:

The management of DEV’s anxiety will start from home, with Dev’s mother and support system intervening and talking to him about his worries and fears and introducing any help available. However, a combination of pharmacological and psychological approaches is advised due to the severity of Dev’s anxiety.

Plan for psychotherapy:
Introducing psychotherapy in treating DEV is crucial as it will involve structured interactions to assist him in changing his behavior, and improving his mood, thereby overcoming his phobia and improving his happiness. Motivation and commitment are fundamental to optimizing the benefits of psychotherapy for DEV, and family involvement cannot be underestimated as DEV is a minor. In considering the impact of mental health on the family and loved ones, planning psychotherapy that will involve DEV and his family is essential. Cognitive behavioral therapy (CBT), also known as a talk show, is one of the psychotherapies I recommend for DEV and family. CBT is a form of psychotherapy that will provide an enabling environment to discuss tips that will guide the patient in managing his symptoms while assisting the family in building group involvement that fosters support for DEV. All the negative thought processes DEV has identified will be corrected through CBT.

Pharmacological Intervention:
CBT combined with an SSRI or SNRI can significantly reduce anxiety. Starting DEV on a low dose of Prozac 10mg ( fluoxetine) and increasing gradually based on the patient’s response up to 20mg daily will be ideal. Educating Dev’s mother on the real-life modification for Dev to prevent enuresis will be part of his treatment plan. Decreasing liquid consumption at hours of sleep, intermittent awakening to offer Dev bathroom privileges, and assisting DEV with personal hygiene and grooming to promote healthy self-esteem will be part of the treatment plans. Referring and making available community resources for DEV and his mother in his zip code, a crisis hotline, and how to make emergency 911 calls will be integrated into the treatment plan.

Alternative therapies

In recommending alternative therapies, the severity of the anxiety attack must be established. Mild anxiety can be treated with alternative therapies only, but moderate and severe anxiety disorders can be treated with a combination of traditional treatment comprising medications and counseling. A lifestyle modification for DEV is crucial, ensuring he avoids drinks and a diet containing caffeine, such as soda and energy drinks. The introduction of nutritional psychiatry to review the impact of nutrition on stress, mental health, and function will be helpful as some nutrients are noted to alter the neurotransmitters dopamine and serotonin to decrease anxiety. A typical example of such nutrients includes omega-3 fatty acids from aquatic life like fish. Although there are divided opinions on the effect of diet in relieving anxiety symptoms, a well-balanced diet devoid of excess sugar and processed food with adequate rehydration is advised. Eating foods that contain B vitamins, vitamin C, magnesium, and zinc with reduced saturated fats and high in fiber and vegetables is encouraged. Assisting DEV with regular exercise and relaxation techniques such as yoga, music, and massage therapy with some breathing techniques can reduce anxiety.

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

In the interim, a one-week follow-up appointment for Dev is recommended to monitor, adjust and evaluate the new medication.  Prosac exhibits side effects similar to anxiety, such as insomnia, headache, nervousness, high risk for bleeding, and antidepressant discontinuation syndrome; monitoring DEV’s response to this medication is vital. It is essential to follow up again in one month via psyche telehealth to evaluate all the referrals and the combined effects of all team collaborations.

Incorporate one health promotion activity and one patient education:

One patient education I will integrate into DEV’s management is using alternative therapies, also known as complementary therapies. It is essential to let DEV and Mom know that despite shreds of individual testimonies on how alternative therapies have enhanced the relief of anxiety symptoms, their efficacy has not been scientifically proven. Verifying with their provider before using it is vital to avoid interaction or contradiction with medications. It should not replace any medicine or therapy given by the doctor. I will also introduce psychoeducation to help DEV and his support system learn about his anxiety which will help identify the early onset and timely intervention. One health promotion activity that I will incorporate in managing DEV’s anxiety is interpersonal and social rhythm therapy to synchronize DEV’s daily habits and activities. Such activities include sleeping, eating, exercising, etc. If DEV appropriately embraces these activities, they can help reduce his anxiety and prevent panic attacks.

Reflection:

As an MHNP, it is essential to note that effective patient management starts with the first encounter. Observing the patient’s non-verbal language as he walks into the clinic will give the clinician a clue on what to expect from the patient. Obtaining a thorough patient history, establishing a trusting relationship, and respecting the patient’s sexuality, religion, cultural differences, and social and economic disparities are types of information gathered when a thorough history is obtained. Developing a patient-provider rapport while maintaining a therapeutic boundary is vital to a trusting interaction. Incorporating cultural competency to reveal a trusting relationship with the patient, respect for his cultural and religious diversities, and establish equity, fairness, and social justice should form the foundation of client-provider interactions.

What I can do differently:
My initial encounter with DEV will include a child attachment interview protocol (CAI) to validate the family situation from the child’s point of view. I will ask DEV questions using an open-ended method, such as telling me three words that describe him and what type of person he thinks he is. Does he have enough food at home? The goal is to initiate a therapeutic alliance and assess safety. Although Dev did not give any suicidal clue, this must be kept in mind. Another thing I will do differently is, based on Dev’s response to treatment; I may introduce contingency management therapy, a form of behavioral therapy that uses stimulus control and consequences to change behavior. Dev will be reinforced or rewarded for evidence of positive behavioral change toward his grooming, ability to stay in school, and reduction in his vague anxiety. Dev’s Mom and baby brother can do some fun activities at home, such as mind-body techniques, nutrition, exercise, and herbs may help reduce anxiety. Progressive muscle relaxation, diaphragmatic breathing, biofeedback, meditation, and self-hypnosis can help DEV relax and reduce stress. Music therapy, visual imagery, and aromatherapy may also help reduce feelings of anxiety.

Legal and Ethical Considerations:

Ethical codes and laws guide decision-making in clinical practice. It represents the minimum standards of care and the highest goals for the patient. As MHNPs, we have legal and ethical responsibilities toward the vulnerable group we treat. Maintaining therapeutic alliance when Dev is referred to psychotherapy is the practitioner’s legal and moral responsibility as the patient’s advocate. The clinician has the ethical and legal obligation to refer and provide patients with community resources to prevent relapse. Educating the patent on legislative laws imparting the patient’s zip code. Issues related to informed consent, confidentiality, conflict of interest, therapeutic misconception, placebo-related vulnerability, exploitation, and operational challenges are some legal and ethical issues the practitioner may face in managing DEV. Focused SOAP Note for Anxiety, PTSD, and OCD – NRNP-6675 Week 3: Assignment

 

References

Blease, C. R., Arnott, T., Kelley, J. M., Proctor, G., Kube, T., Gaab, J., &Locher, C. (2020). Attitudes About Informed Consent: An Exploratory Qualitative Analysis of UK Psychotherapy Trainees. Frontiers in Psychiatry, 11. doi:10.3389/fast.2020.00183

Baillie, A. J. (2010). Are you investigating differential symptom profiles in a major depressive episode with and without generalized anxiety disorder: true co-morbidity or symptom similarity? Psychological medicine, 40(7), 1113–1123.
https://doi.org/10.1017/S0033291709991590

Bipeta, R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian Journal of  Psychological Medicine, 41(2), 108–112. doi:10.4103/ijpsym.ijpsym_59_19

Stein M. B. (2006). An epidemiologic perspective on social anxiety disorder. The Journal of clinical psychiatry, 67 Suppl 12, 3–8.

Lamont, S., Stewart, C., & Chiarella, M. (2017). Capacity and consent: Knowledge and practice of legal and healthcare standards. Nursing Ethics, 26(1), 71–83.

doi:10.1177/0969733016687162

Rosenthal, Rosenjack, J., & Laura D. / Burchum. (2018). Lehne’s Pharmacotherapeutics for Nurse Practitioners and Physician Assistants (2nd ed.). Elsevier Course Content Deliv

Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (Eds.). (2015). Rutter’s child and adolescent psychiatry (6th ed.). Wiley Blackwell.

Zakhari, R. (2021). The psychiatric-mental health nurse practitioner certification review manual. Springer Publishing Company

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.

 

Focused SOAP Note for Anxiety, PTSD, and OCD – NRNP-6675 Week 3: Assignment

Focused SOAP Note for Anxiety, PTSD, and OCD

In assessing patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders, you will continue the practice of looking to understand chief symptomology in order to develop a diagnosis. With a differential diagnosis in mind, you can then move to a treatment and follow-up plan that may involve both psychopharmacologic and psychotherapeutic approaches.

In this Assignment, you use a case study to develop a focused SOAP note based on evidence-based approaches.

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 this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing anxiety, obsessive compulsive, and trauma-related disorders.

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: Dev Cordoba
. 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, listed 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. Focused SOAP Note for Anxiety, PTSD, and OCD – NRNP-6675 Week 3: Assignment

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 could 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 3

Submit your Focused SOAP Note.

submission information

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 from the 
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, save your Assignment as 
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Rubric

NRNP_6675_Week3_Assignment_Rubric

NRNP_6675_Week3_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

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

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 Focused SOAP Note for Anxiety, PTSD, and OCD – NRNP-6675 Week 3: Assignment

5
 pts

Total Points: 
100