PRAC – 6665 Week 3: Focused SOAP Note and Patient Case Presentation
PRAC – 6665 Week 3: Focused SOAP Note and Patient Case Presentation
| What do I have to do? | When do I have to do it? |
| Review your Learning Resources. | Days 1–7 |
| Assignment 1: Clinical Hour and Patient Logs | Record your clinical hours and patient encounters in Meditrek by Day 7. |
| Assignment 2: Focused SOAP Note and Patient Case Presentation | Submit by Day 7. |
Introduction
Consider the experiences you have had thus far, either in the healthcare workplace or at your practicum site. As you likely know, a nurse’s job does not begin and end with one-to-one patient contact. It includes meetings, documentation, trainings, and collaboration. In particular, the nurse is a member of an interdisciplinary team and must use oral and written communication to inform others of a patient’s status. A central skill of advanced practice nursing, then, is the ability to present a patient’s history, symptoms, diagnosis, and treatment plan to relevant parties involved in treatment.
This week, in addition to your Meditrek tracking, you will develop a focused SOAP note and video case presentation on one of the patients you have examined in your clinical practicum.
Learning Objectives
Students will:
- Describe clinical hours and patient encounters
- Assess patients across the lifespan in mental health settings
- Formulate differential diagnoses for patients across the lifespan in mental health settings
- Develop plans of care for patients across the lifespan in mental health settings
- Advocate health promotion and patient education strategies across the lifespan
- Develop a case study presentation based on a clinical patient
Learning Resources
Required Readings
Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
- Section II. The Psychiatric History (Chapters 14–18)
- Section III. Interviewing for Diagnosis: The Psychiatric Review of Symptoms (Chapters 23–24)
Meditrek https://edu.meditrek.com/Default.html
Note: Use this link to log into Meditrek to report your clinical hours and patient encounters.
Document: Focused SOAP Note Template (Word document)
Assignment 1: Clinical Hour and Patient Logs
Photo Credit: auremar / Adobe Stock
Clinical Hour Log
For this course, all practicum activity hours are logged within the Meditrek system. Hours completed must be logged in Meditrek within 48 hours of completion in order to be counted.
You may only log hours with Preceptors that are approved in Meditrek. Students with catalog years before Spring 2018 must complete a minimum of 576 hours of supervised clinical experience (144 hours in each practicum course). Students with catalog years beginning Spring 2018 must complete a minimum of 640 hours of supervised clinical experience (160 hours in each practicum course).
Each log entry must be linked with an individual practicum Learning Objective or a graduate Program Objective. You should track your hours in Meditrek as they are completed.
Your clinical hour log must include the following:
- Dates
- Course
- Clinical Faculty
- Preceptor
- Total Time (for the day)
- Notes/Comments (including the objective to which the log entry is aligned)
Patient Log
Throughout this course, you will also keep a log of patient encounters using Meditrek. You must record at least 80 encounters with patients by the end of this practicum (40 children/adolescents and 40 adult/older adult).
The patient log must include the following:
- Date
- Course
- Clinical Faculty
- Preceptor
- Patient Number
- Client Information
- Visit Information
- Practice Management
- Diagnosis
- Treatment Plan and Notes: You must include a brief summary/synopsis of the patient visit. This does not need to be a SOAP note, however the note needs to be sufficient to remember your patient encounter.
By Day 7 of Week 3
Record your clinical hours and patient encounters in Meditrek.
Assignment 2: Focused SOAP Note and Patient Case Presentation
Photo Credit: Pexels
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
- Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
- Select a patient of any age (either a child or an adult) that you examined during the last 3 weeks.
- Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.
Please Note:- All SOAP notes must be signed, and each page must be initialed by your Preceptor. Note: Electronic signatures are not accepted.
- 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.
- You must submit your SOAP note using SafeAssign. Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.
- Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record.
- 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.
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The Assignment
Record yourself presenting the complex case study for your clinical patient. In your presentation:
- Dress professionally with a lab coat and present yourself in a professional manner. PRAC – 6665 Week 3: Focused SOAP Note and Patient Case Presentation
- Display your photo ID at the start of the video when you introduce yourself.
- Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
- 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.
- Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide:
- 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: What was your plan for psychotherapy? What was 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 be sure to include at least 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? 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.
By Day 7 of Week 3
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.
Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:
- Please save your Assignment using the naming convention “WK3Assgn2+last name+first initial.(extension)” as the name.
- Click the Week 3 Assignment 2 Rubric to review the Grading Criteria for the Assignment.
- Click the Week 3 Assignment 2 link. You will also be able to “View Rubric” for grading criteria from this area.
- Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK3Assgn2+last name+first initial.(extension)” and click Open.
- If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
- Click on the Submit button to complete your submission.
Grading Criteria
To access your rubric:
Week 3 Assignment 2 Rubric
What’s Coming Up in Week 4?
Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
Next week, you will continue your clinical hour and patient logs in Meditrek. The week’s resource selections will support your knowledge of assessing and treating mood disorders.
Next Week
To go to the next week:
