Subjective Data
The Chief Complaint is clear, concise, and verbatim from pt. History of Present Illness is thorough yet concise and provides a chronological account of symptoms and contextual factors that are sufficiently descriptive (OLDCARTS) to validate Dx per DSM-5 TR criteria. Besides, all pertinent negatives are included. A longitudinal course of illness is clear. Current psychiatric medications and responses are included. NSG5906 Week 3 SOAP Note
Objective Data
MSE contains the required elements. It is in narrative form and effectively and vividly describes the patient’s presentation. Concrete examples of all assessment results are included i.e. “able to correctly interpret 2/3 simple proverbs” to validate documentation of “abstract thought intact.”
Assessment
The differential is pertinent to signs and symptoms, the formulation contains evidence of critical thought and subject knowledge, and reasonable diagnoses are made per DSM-5. Clearly met criteria for diagnoses tendered are explicit in the HPI (History of Present Illness) description and substantiated with the MSE.
Plan
An evidence-based treatment plan is presented with detailed rationales. The level of detail reflects the student’s ability to choose treatments based not only on FDA approval or current evidence but also on the nuances and unique characteristics of each. Additionally, the treatment plan is holistic and comprehensive. Furthermore, ensure that there is compelling evidence of the student’s synthesis of information and critical thought. Includes neurobiology information on the disorder. NSG5906 Week 3 SOAP Note
Writing, Support, APA
The format is consistent with the example provided in the course. Clear, recent (5-7 years), scholarly, peer-reviewed support of topics. Fewer grammar, spelling, and punctuation errors. Moreover, writing mechanics include minimal awkward or unclear passages but are consistent with formal scholarly work. There are minimal errors in APA style manuals listed on the course syllabi.
Physical Examination
General
Eyes
Ears/Nose/Throat
Endocrine
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Hematology/Lymph
Integumentary
Neck
Neurological
Musculoskeletal
Psychological
Vital signs
• BP
• Temp
• Pulse
• RR
• Height
• Weight
• BMI
• Include normal, overweight, obese, etc.
Physical Examination including
• Eyes
• Ears/Nose/Throat
• Endocrine
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Hematology/
Lymph
• Integumentary
• Neck
• Neurological
• Musculoskeletal
• Psychological
NSG5906 Week 3 SOAP Note; Mental Health Exam Including
• Level of alertness: Comment on the patient consciousness. If not, can they be aroused? Can they remain focused on your questions and conversation? What is their attention span?
• Speech: Is it normal in tone, volume and quantity?
• Behavior: Pleasant? Cooperative? Agitated? Appropriate for the particular situation?
• Awareness of environment: Does the client know where they are and what they are doing here? Do they know who you are? Can they tell you the day, date and year?
• Mood: How do they feel? You may ask this directly. According to you, is it appropriate for their current situation?
• Affect: What is your judgement of their appearance? This interpretation is based on your observation of their interactions during the interview.
• Furthermore, Thought Process: This is a description of the way in which they think. Instead, are their comments logical and presented in an organized fashion? If not, how off base are they? Also, do they tend to stray quickly to related topics? Are their thoughts appropriately linked or simply all over the map? emphatically, conversely,
• Finally, Thought Content: A description of what the patient is thinking about. Looking at the thought content of the patient, are they paranoid? Basically, are they delusional (i.e. hold beliefs that are untrue)? If so, about what? Phobic? despite,