PRAC 6665 Assignment: SOAP Note and Patient Case Presentation

PRAC 6665 Assignment: SOAP Note and Patient Case Presentation

Sample Answer for PRAC 6665 Assignment: SOAP Note and Patient Case Presentation Included After Question

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.

PRAC 6665 Assignment SOAP Note and Patient Case Presentation
PRAC 6665 Assignment SOAP Note and Patient Case Presentation

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.
  • 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.

PRAC 6665 Assignment: SOAP Note and Patient Case Presentation Grading Criteria

To access your rubric:

Week 3 Assignment 2 Rubric

 

Check Your Assignment Draft for Authenticity

To check your Assignment draft for authenticity:

Submit your Week 3 Assignment 2 draft and review the originality report.

Submit Your Assignment by Day 7 of Week 3

To participate in this Assignment:

Week 3 Assignment 2

PRAC 6665 Assignment: SOAP Note and Patient Case Presentation Grading Rubric

Performance Category 100% or highest level of performance

100%

16 points

 Very good or high level of performance

88%

14 points

 Acceptable level of performance

81%

13 points

 Inadequate demonstration of expectations

68%

11 points

 Deficient level of performance

56%

9 points

 

 Failing level

of performance

55% or less

0 points
 Total Points Possible= 50           16 Points    14 Points 13 Points        11 Points           9 Points          0 Points
Scholarliness

Demonstrates achievement of scholarly inquiry for professional and academic topics.

 Presentation of information was exceptional and included all of the following elements:

  • Provides evidence of scholarly inquiry relevant to required TD topic(s).
  • Presents specific information from scholarly sources to develop a comprehensive presentation of facts.
  • Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.*
  • Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.
 Presentation of information was good, but was superficial in places and included all of the following elements:

  • Provides evidence of scholarly inquiry relevant to required TD topic(s).
  • Presents specific information from scholarly sources to develop a comprehensive presentation of facts.
  • Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.*
  • Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.
 Presentation of information was minimally demonstrated in all of the following elements:

  • Provides evidence of scholarly inquiry relevant to required TD topic(s).
  • Presents specific information from scholarly sources to develop a comprehensive presentation of facts.
  • Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.*
  • Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.
  

Presentation of information is unsatisfactory in one of the following elements:

  • Provides evidence of scholarly inquiry relevant to required TD topic(s).
  • Presents specific information from scholarly sources to develop a comprehensive presentation of facts.
  • Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.*
  • Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.
  

Presentation of information is unsatisfactory in two of the following elements:

  • Provides evidence of scholarly inquiry relevant to required TD topic(s).
  • Presents specific information from scholarly sources to develop a comprehensive presentation of facts.
  • Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.*
  • Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.
 Presentation of information is unsatisfactory in three or more of the following elements

  • Provides evidence of scholarly inquiry relevant to required TD topic(s).
  • Presents specific information from scholarly sources to develop a comprehensive presentation of facts.
  • Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.*
  • Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information
 16 Points  14 Points  13 Points 11 Points 9 Points  0 Points
Application of Course Knowledge

Demonstrate the ability to analyze and apply principles, knowledge and information learned in the outside readings and relate them to real-life professional situations

 Presentation of information was exceptional and included all of the following elements:

  • Applies principles, knowledge and information from scholarly resources to the required topic.
  • Applies facts, principles or concepts learned from scholarly resources to a professional experience.
  • Application of information is comprehensive and specific to the required topic.
 Presentation of information was good, but was superficial in places and included all of the following elements:

  • Applies principles, knowledge and information from scholarly resources to the required topic.
  • Applies facts, principles or concepts learned from scholarly resources to a professional experience.
  • Application of information is comprehensive and specific to the required topic.
 Presentation of information was minimally demonstrated in the all of the following elements:

  • Applies principles, knowledge and information from scholarly resources to the required topic.
  • Applies facts, principles or concepts learned from scholarly resources to a professional experience.
  • Application of information is comprehensive and specific to the required topic.
 Presentation of information is unsatisfactory in one of the following elements:

  • Applies principles, knowledge and information from scholarly resources to the required topic.
  • Applies facts, principles or concepts learned from and scholarly resources to a professional experience.
  • Application of information is comprehensive and specific to the required topic.
 Presentation of information is unsatisfactory in two of the following elements:

  • Applies principles, knowledge and information from scholarly resources to the required topic.
  • Applies facts, principles or concepts learned from scholarly resources to a professional experience.
  • Application of information is comprehensive and specific to the required topic.
 Presentation of information is unsatisfactory in three of the following elements

  • Applies principles, knowledge and information and scholarly resources to the required topic.
  • Applies facts, principles or concepts learned scholarly resources to a professional experience.
  • Application of information is comprehensive and specific to the required topic.
   10 Points 9 Points  6 Points  0 Points
Interactive Dialogue

Initial post should be a minimum of 300 words (references do not count toward word count)

The peer and instructor responses must be a minimum of 150 words each (references do not count toward word count)

Responses are substantive and relate to the topic.

 Demonstrated all of the following:

  • Initial post must be a minimum of 300 words.
  • The peer and instructor responses must be a minimum of 150 words each.
  • Responses are substantive
  • Responses are related to the topic of discussion.
 Demonstrated 3 of the following:

  • Initial post must be a minimum of 300 words.
  • The peer and instructor responses must be a minimum of 150 words each.
  • Responses are substantive
  • Responses are related to the topic of discussion.
 Demonstrated 2 of the following:

  • Initial post must be a minimum of 300 words.
  • The peer and instructor responses must be a minimum of 150 words each.
  • Responses are substantive
  • Responses are related to the topic of discussion.
 Demonstrated 1 or less of the following:

  • Initial post must be a minimum of 300 words.
  • The peer and instructor responses must be a minimum of 150 words each.
  • Responses are substantive
  • Responses are related to the topic of discussion.
  8 Points 7 Points  6 Points         5 Points          4 Points  0 Points
Grammar, Syntax, APA

Points deducted for improper grammar, syntax and APA style of writing.

The source of information is the APA Manual 6th Edition

Error is defined to be a unique APA error. Same type of error is only counted as one error.

 The following was present:

  • 0-3 errors in APA format

AND

  • Responses have 0-3 grammatical, spelling or punctuation errors

AND

  • Writing style is generally clear, focused on topic,and facilitates communication.
 The following was present:

  • 4-6 errors in APA format.

AND/OR

  • Responses have 4-5 grammatical, spelling or punctuation errors

AND/OR

  • Writing style is somewhat focused on topic.
 The following was present:

  • 7-9 errors in APA format.

AND/OR

  • Responses have 6-7 grammatical, spelling or punctuation errors

AND/OR

  • Writing style is slightly focused on topic making discussion difficult to understand.
  

The following was present:

  • 10- 12 errors in APA format

AND/OR

  • Responses have 8-9 grammatical, spelling and punctuation errors

AND/OR

  • Writing style is not focused on topic, making discussion difficult to understand.
  

The following was present:

  • 13 – 15 errors in APA format

AND/OR

  • Responses have 8-10 grammatical, spelling or punctuation errors

AND/OR

  • Writing style is not focused on topic, making discussion difficult to understand.

AND/OR

  • The student continues to make repeated mistakes in any of the above areas after written correction by the instructor.
 The following was present:

  • 16 to greater errors in APA format.

AND/OR

  • Responses have more than 10 grammatical, spelling or punctuation errors.

AND/OR

  • Writing style does not facilitate communication
  0 Points Deducted 5 Points Lost
Participation

Requirements

Demonstrated the following:

  • Initial, peer, and faculty postings were made on 3 separate days
 Failed to demonstrate the following:

  • Initial, peer, and faculty postings were made on 3 separate days
  0 Points Lost 5 Points Lost
Due Date Requirements Demonstrated all of the following:

  • The initial posting to the graded threaded discussion topic is posted within the course no later than Wednesday, 11:59 pm MT.

A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT.

Demonstrates one or less of the following.

  • The initial posting to the graded threaded discussion topic is posted within the course no later than Wednesday, 11:59 pm MT.

A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT.