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

Assignment: 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. 

To Prepare

  • Review this week’s Learning Resources. Consider the insights they provide about assessing, diagnosing, and treating schizophrenia spectrum, other psychotic, and medication-induced movement 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: 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).

 

Rubric Detail

 

Select Grid View or List View to change the rubric’s layout.

 

Name: NRNP_6675_Week5_Assignment_Rubric

 

Excellent 90%–100%

Good 80%–89%

Fair 70%–79%

Poor 0%–69%

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

14 (14%) – 15 (15%)

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.

12 (12%) – 13 (13%)

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 (11%) – 11 (11%)

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.

0 (0%) – 10 (10%)

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.

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

14 (14%) – 15 (15%)

The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.

12 (12%) – 13 (13%)

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.

11 (11%) – 11 (11%)

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.

0 (0%) – 10 (10%)

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.

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.

18 (18%) – 20 (20%)

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.

16 (16%) – 17 (17%)

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.

14 (14%) – 15 (15%)

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.

0 (0%) – 13 (13%)

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.

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.

23 (23%) – 25 (25%)

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.

20 (20%) – 22 (22%)

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.

18 (18%) – 19 (19%)

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.

0 (0%) – 17 (17%)

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.

• 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 (5%) – 5 (5%)

Reflections are thorough, thoughtful, and demonstrate critical thinking. Reflections contain a discussion of all elements described within assignment directions.

4 (4%) – 4 (4%)

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 (3.5%) – 3.5 (3.5%)

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.

0 (0%) – 3 (3%)

Reflections are incomplete, inaccurate, or missing.

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).

9 (9%) – 10 (10%)

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 (8%) – 8 (8%)

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 (7%) – 7 (7%)

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.

0 (0%) – 6 (6%)

Two or fewer resources are provided to support the assessment and diagnosis decisions. The resources may not be current or evidence based.

Written Expression and Formatting – The paper follows correct APA format for parenthetical/in-text citations and reference list.

5 (5%) – 5 (5%)

Uses correct APA format with no errors

4 (4%) – 4 (4%)

Contains 1-2 grammar, spelling, and punctuation errors

3.5 (3.5%) – 3.5 (3.5%)

Contains 3-4 grammar, spelling, and punctuation errors

0 (0%) – 3 (3%)

Contains five or more grammar, spelling, and punctuation errors that interfere with the reader’s understanding

Written Expression and Formatting – English Writing Standards:

Correct grammar, mechanics, and punctuation

5 (5%) – 5 (5%)

Uses correct grammar, spelling, and punctuation with no errors

4 (4%) – 4 (4%)

Contains 1-2 APA format errors

3.5 (3.5%) – 3.5 (3.5%)

Contains 3-4 APA format errors

0 (0%) – 3 (3%)

Contains five or more APA format errors

 

Total Points: 100

Walden University. (2021). Case study: Sherman Tremaine. Walden University Blackboard. https://class.waldenu.edu 

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