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. Include all pertinent negatives. A longitudinal course of illness is clear and includes the current psychiatric medications and responses. NSG5906 Week 5 SOAP Note
Objective Data:
MSE contain the required elements and that 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. Also, ensure you meet criteria for diagnoses tendered are explicit in the HPI (History of Present Illness) description and substantiated with the MSE.
Plan
The work presents an evidence-based treatment plan 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. Besides, present a holistic and comprehensive treatment plan. Additionally, a compelling evidence of the student’s synthesis of information and critical thought is presented. This includes neurobiology information on the disorder.
Writing, Support, APA
Use a format that is consistent with the example provided in the course. Use clear, recent (5-7 years), scholarly, and peer-reviewed articles. Minimal grammar, spelling, and punctuation errors. Additionally, writing mechanics include minimal awkward or unclear passages but are consistent with formal scholarly work. Additionally, endeavor to minimize gramatical errors in APA style manuals listed on the course syllabi.