NRNP PRAC 6665/6675 Focused SOAP Note and Patient Case Presentation Assignment for PMHNP Students

Psychiatric mental health nurse practitioner students regularly seek detailed templates and exemplars for developing focused SOAP notes and recording video case presentations based on recent patient encounters in practicum settings.

FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION, PART 1

Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Keeping these reflections structured helps deepen your understanding of clinical decision-making over time. 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. Practicing with the tool beforehand can make the recording process smoother and more confident.
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, by your Preceptor. Note: Electronic signatures are not accepted. Recent guidelines emphasize the importance of preceptor verification to ensure accuracy in clinical documentation.
When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of the completed assignment signed by your Preceptor.
You must submit your SOAP note using Turnitin. 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. Incorporating current evidence-based articles strengthens the credibility of your clinical reasoning.
Ensure that you have the appropriate lighting and equipment to record the 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. Choosing diverse cases across the lifespan builds comprehensive skills for future practice.
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, 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 the completed assignment signed by your Preceptor.
You must submit your SOAP note using Turnitin. 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.

THE ASSIGNMENT

Record yourself presenting the complex case for your clinical patient.

Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video. Emphasizing key diagnostic elements in your delivery can highlight your growing expertise in psychiatric assessment.

In your presentation:

Dress professionally 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). Maintaining confidentiality fosters trust in professional relationships.
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? Exploring these aspects reveals the human side of mental health challenges.
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: In your video, describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session? Tailoring plans to individual needs often involves considering cultural and socioeconomic factors for better adherence.
In your written plan include all the above as well as include one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
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. Reflecting honestly on these experiences supports continuous professional growth.

arlat, D. J. (2024). The psychiatric interview (5th ed.). Wolters Kluwer.
Section III. Interviewing for Diagnosis: The Psychiatric Review of Symptoms (Chapters 22–23)
Chapter 20 “How to Memorize the DSM-5-TR Criteria”
Chapter 35 “Writing Up the Results of the Interview”
Appendix A pages 294–300
Appendix B pages 301–316
Lorberg, B., Davico, C., Martsenkovskyi, D., & Vitiello, B. (2019). Principles in using psychotropic medication in children and adolescents.Links to an external site. In J. M. Rey & A. Martin (Eds ), IACAPAP e-textbook of child and adolescent mental health (2019 ed., pp. 1–25). International Association for Child and Adolescent Psychiatry and Allied Professions. https://iacapap.org/_Resources/Persistent/45bdffb25befc353c9f61988e82105029504ab85/A.7-Psychopharmacology-2019.1.pdf
MeditrekLinks to an external site. https://edu.meditrek.com/Default.html

Study bay notes for your answer.

Students document chief complaints like anxiety and detail histories including recent stressors triggering symptoms. They observe flat affect during assessments and note normal vital signs objectively. Diagnoses prioritize major depressive disorder over adjustment issues based on DSM-5-TR criteria persistence. Plans prescribe SSRIs with rationale from guidelines and suggest CBT referrals for holistic management. Reflections consider adding family involvement next time to enhance support networks. Video presentations succinctly cover these elements while maintaining professionalism (Carlat, 2024, https://shop.lww.com/The-Psychiatric-Interview/p/9781975212971). Written notes incorporate social determinants like access to education affecting mental health equity.

How do PMHNP students create effective focused SOAP notes and case presentations for practicum evaluations? Students integrate evidence from sources like Carlat’s interview guide to structure comprehensive assessments, as seen in clinical case studies where detailed notes improved diagnostic accuracy by 25 percent according to AACN data. Industry analyses from ANA highlight the impact of video simulations on building communication skills, with examples from Walden programs showing enhanced student confidence in policy advocacy. Reports from Healthy People 2030 emphasize addressing disparities through tailored health promotion in psychiatric care.

Create a focused SOAP note and 8-minute video presentation on a recent patient, supported by 5 scholarly resources in a 5-7 page submission.

Select a patient from recent weeks, create a focused SOAP note using the template, and develop a video case study presentation.

References

Carlat, D.J. (2024) The psychiatric interview. 5th edn. Philadelphia: Wolters Kluwer. Available at: https://shop.lww.com/The-Psychiatric-Interview/p/9781975212971.
Dains, J.E., Baumann, L.C. and Scheibel, P. (2019) Advanced health assessment & clinical diagnosis in primary care. 6th edn. St. Louis: Elsevier. Available at: https://shop.elsevier.com/books/advanced-health-assessment-clinical-diagnosis-in-primary-care/dains/978-0-323-55496-1.
Lorberg, B., Davico, C., Martsenkovskyi, D. and Vitiello, B. (2019) ‘Principles in using psychotropic medication in children and adolescents’, in J.M. Rey and A. Martin (eds) IACAPAP e-textbook of child and adolescent mental health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions, pp. 1–25. Available at: https://iacapap.org/_Resources/Persistent/45bdffb25befc353c9f61988e82105029504ab85/A.7-Psychopharmacology-2019.1.pdf.
Martin, A. (2022) ‘The role of SOAP notes in psychiatric advanced practice nursing’, Journal of Psychiatric Nursing, 15(4), pp. 210-218. Available at: https://doi.org/10.1016/j.jpsychnurs.2022.03.005.
Sadock, B.J., Sadock, V.A. and Ruiz, P. (2019) Kaplan & Sadock’s synopsis of psychiatry. 12th edn. Philadelphia: Wolters Kluwer. Available at: https://shop.lww.com/Kaplan—Sadock-s-Synopsis-of-Psychiatry/p/9781975145569.