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 pr

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Week 3: Focused SOAP note

Shannon Pierce

College of Nursing-PMHNP, Walden University

PRAC 6665: PMHNP Care Across the Lifespan I

Faculty Name

Assignment Due Date

Subjective:

CC: “I made a stupid comment that I was going to hurt myself after an argument with family over my aunts house”

HPI: K.T. is a 50 year old female who present to the Pavilion under a TDO after making suicidal threats of self harm after having a verbal altercation with family members. She was referred to this facilty for further help with her mental illness. K.T has been having feeling of anxiety and contribute that to stresssors in her life which at this time she does not care to elaborate on. Suicisal comments were made by client with no intent on acting out on thoughts.

Substance Current Use: K.T drinks a daily 8 oz cup of coffee, black wih 3 sugars. She denies the use of cigarrets and no marijuana use. Client does not engage in any ilicit drug activity. Client does have am extensive history of alcohol abuse which she us now struggling with but mostly abstinent for 1-2 years. Client sought rehabilitation in the past and has had a recent relapse. Last drink was 3/6/24. Client admits to drinking 3-4 times a week of a liter of wine.

Medical History: patient with a history of hypertension, GERD, insomnia, migraine, anemia, hepatic stenosis and epilepsy

Current Medications: Abilify 5 mg at bedtime for depression, Norvasc 5 mg daily for hypertension, ;ipitor 40 mg every night for hyperlipidemia, hydrochlorathiazide 25 mg daily for hypertension, lisinopril 25 mg daily for hypertension, phenobarbital 64.8 mg taper for alcohol withdrawal, Lyrica 75 mg B.I.D pain, Zoloft 200 mg at bedtime for depression, ambien 10 mg PRN at bedtime for insomnia, Zanaflex 4 mg every 8 hours while awake for muscle pain
Allergies: Pollen
Reproductive Hx: client no longer having mentsral cycles, menopause, reports no sexual activiety for yers now with husband

ROS:

GENERAL: denies fever and chills, no report of weigt loss, no fatigue.
HEENT: Eyes: no blurred or double vision, no dryness or watering of eyes, white scelra. Ears: no tinnitus, no reports of difficulty hearing. Nose: no nasal drainage, no running nose or congestion. Throat: no sore throat.
SKIN: no rash, no itching, scratches noted to inner left wrist, dry, flaky skin
CARDIOVASCULAR: no murmur, no edema, no chest pressure of tightness, no palpitations.
RESPIRATORY: no cough, no shortness of breath, lung clear bilaterally
GASTROINTESTINAL: no N/V/D and no abdominal pain, no disentention
GENITOURINARY: no dysuria, no frequency, no abnormal color or odor.
NEUROLOGICAL: no headache, no numbness or tingling in extremities, no tremors. Last seizure notedf to be two years ago, no falls
MUSCULOSKELETAL: no stiffness, back pain related tol back surgery in the past, no joint pain
HEMATOLOGIC: amemia, no brusing noted and no active bleeding
LYMPHATICS: no enlarged nodes
ENDOCRINOLOGIC: no heat or cold intolerance, no sweats

Objective:

Diagnostic results:

Assessment:

Mental Status Examination: K.T is a 50 year old Caucasian female who presents here stated age but unkept with matted hair. She is cooperative during interview but irritated in deameanor when asked questions. There is no evidence of any abnormal motor activity. Her speech is lound and pressured at times. Her thought process is somewhat impaired. Thought content is within normal limits. Her mood id angry, and her affect is labile. She denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. She has little insight and judgement is poor . Currently she denies any homicidal or suicidal ideations. Cognitively, she is alert and oriented X 3. Her recent and remote memory is intact. His concentration is decreasd as she suffers from ADHD.

Diagnostic Impression:

Reflections:

Case Formulation and Treatment Plan:

PRECEPTOR VERFICIATION:

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

Preceptor signature: ________________________________________________________

Date: ________________________

References