The focus is on your ability to integrate your subjective and objective information gathering into the formulation of diagnoses and the development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions (Initial Psychiatric Interview/SOAP Note Sample) psychiatric interview techniques
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Unit 6 Assignment – Clinical: SOAP Note (Sample Initial Psychiatric Interview for Schizophrenia)
Start Assignment psychiatry interview questions
Instructions
Each week students will choose one patient encounter to submit a Follow-up SOAP note for review.
Follow the rubric to develop your SOAP notes for this term.
The focus is on your ability to integrate your subjective and objective information gathering into the formulation of diagnoses and the development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.
Note: Grades of Incomplete on this assignment will result in a clinical failure.
Initial Psychiatric Interview / SOAP Note
| Criteria | Clinical Notes |
| Informed Consent | The patient gave the psychiatrist his (patient’s) verbal and written consent about the psychiatric interview process and any subsequent psychiatric or psychotherapy interventions that may follow. The patient demonstrates the ability and capacity to answer and appears to understand the risks and benefits of the treatment plan. (Initial Psychiatric Interview/SOAP Note Sample) |
| Subjective ((Initial Psychiatric Interview/SOAP Note Sample) | Verify Patient Name: Alpha Bertrand (A.B) DOB: 02/17/1978 Minor: N/A Accompanied by: Yeagar Zachary(Y.Z) -A cousin who shares the same apartment with A.B. Demographic: The patient is a 44-year-old Caucasian American Indian male brought to the facility by a relative from home in the Western side of Washington DC low social-economic suburb, United States. The patient presents for follow-up treatment c/o paranoid schizophrenia. A.B. rents an apartment in Washington, D.C, and is a part-time worker. He was living with his spouse of 18 years until seven months ago. He reports that currently, they are estranged, and the wife took away their 17 y/o girls. He reports having a stable network of friends and relatives. Pro-essays.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us (Sample Initial Psychiatric Interview for Schizophrenia). Gender Identifier Note: Male CC: “ I am feeling better compared to my last visit 6 weeks ago” HPI: Mr. AB is a 44 y/o male of American Indian origin with history of schizophrenia and presenting at the clinic for a follow-up clinic. He is currently under prescription medication for psychiatric issues Abilify 15mg, 1tab P.O. q day. The patient reports improvement and can carry on a conversation without mentioning hallucinations and psychotic delusions. His main delusion is believing that his teenage daughter is destined to be the first female U.S. president in the next presidential election but the mother is not a good mentor for her. He also believes the Secret Service has agents assigned to guard him but is now jealous and wants to murder him. Past hallucinations are hearing voices in the room at night that his room cannot hear and detecting swine poop smell in foods that AZ does not taste despite having prepared the meal. However, he rationalizes that these could be unreal sometimes. Exercising,, jogging after work, and healthy dietary intake improve his mood, occupational functioning, and sleep. SI/ HI/ AV: Patient denies suicidal ideations, no homicidal ideations, no incidences of violent behavior, and no issues with the law. Allergies: Positive for sulfa and penicillin allergies that he manages using diphenhydramine hydrochloride 25 mg, 1 PO prn allergies, Past Medical Hx: He also has medical conditions namely hypertension, stress incontinence, and Type 2 Diabetes Mellitus adult-onset for which he is taking HCTZ 20mg 1 P.O. q day, Enablex 7.5 mg 1 P.O. q 6 hours prn, and Metformin hydrochloride 500mg 1 P.O. bid. He also complains of weight gain resulting from increased food intake due to Abilify medication. He has no history of surgical operations. Past Psychiatric Hx: YZ, his 41 y/o cousin whom they share an apartment with reports he sometimes exhibits paranoia believing the Secret Service has placed hitmen in the neighborhood to eliminate him He also sometimes refuses to take some meals to avoid food poisoning. He has experienced depression following the death of his mother when he was 29 years in the past but the strange behavior became manifest after he was robbed on his way home 8 months ago and subsequent separation from his wife a month later. The wife took their daughter with her (his eternal spring of joy –according to patient A.B.). It started off with insomnia, then irritability and a marked lack of motivation. He sought medical intervention when he started seeing things and people others could see, heard nonexistent voices, and tasted things others could not. He also became suspicious of people at the workplace and in the neighborhood, and delusions on about his teenage daughter being the president in waiting of the U.S. although she is still in high school. Pro-essays.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us (Sample Initial Psychiatric Interview for Schizophrenia) Previous psychiatric diagnoses: depression, and anxiety that were successfully managed through medication and cognitive behavioral therapy. Safety concerns: History of Violence to Self: Negative History of Violence to Others : Negative Auditory Hallucinations: Positive hears voices in the room or outside the door that his cousin cannot hear. Visual Hallucinations: Sees non excitement hitmen on rooftops. Mental health treatment history Has history of CBT for depression reinforced with Fluoxetine Hydrochloride 20 mg, 1-tab po q day and Klonopin 1 mg, 1-tab po qhs for anxiety disorder. History of outpatient treatment: 3-month CBT for depression Previous psychiatric hospitalizations: Negative Prior substance abuse treatment: Negative Trauma history: Client denies any past emotional, physical or sexual abuse I childhood Substance Use history: Denies history or substance abuse. Current Medications: Schizophrenia – Abilify 15 mg, 1-tab po q da D.M. adult onset, – metformin hydrochloride 500 mg, 1 po bid, hypertension, – HCTZ 20 mg – 25 mg, 1 po q day, stress incontinence, – Enablex 7.5 mg, 1 po q day and for allergies for sulfa and penicillin- diphenhydramine hydrochloride 25 mg, 1 po prn Supplements: One-A-Day Multivitamin Past Psych Med Trials: Negative Family Medical Hx: Unknown He claims to be an only child of a single parent who died in a car accident. Family Psychiatric Hx: Mother was alcoholic Pro-essays.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us (Sample Initial Psychiatric Interview for Schizophrenia) Social History: Occupational history: currently employed as a part-time mechanic. Military service History: Negative Education History: High school graduate with a vocational certificate in automotive engineering Developmental History: Noncontributory as all developmental milestones were achieved. Legal History: Negative Spiritual/Cultural Considerations: Reports no specific cultural or religious preferences. Pro-essays.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us (Sample Initial Psychiatric Interview for Schizophrenia) ROS: Constitutional: reports slight fever and 15-pound weight gain in the last two months Eyes: Denies acute vision changes or eye pain. ENT: Denies hearing changes or discharge no running nose, no painful throat Cardiac: Denies chest pain, edema, or orthopnea. Respiratory: Denies dyspnea, cough, or wheezing. G.I.: Denies abdominal pain. GU: reports dysuria Musculoskeletal: Negative for joint pain or swelling. Skin: Negative for rash, lesions, and abrasions. Neurologic: No report of seizures, blackout, numbness, or focal weakness. Endocrine: Admits report of polyuria and polydipsia. Hematologic: Negative blood clots or easy bleeding. Allergy: No report of hives or allergic reaction. Reproductive: No report of significant issues. Pro-essays.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us (Sample Initial Psychiatric Interview for Schizophrenia) |
| Verify Patient: Name, Assigned identification number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo. Include demographics, chief complaint, subjective patient information, and the names and relations of others present in the interview. HPI: , Past Medical and Psychiatric History, Current Medications, Previous Psych Med trials, Allergies. Social History, Family History. Review of Systems (ROS) – if ROS is harmful, “ROS noncontributory,” or “ROS negative except….” Pro-essays.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us (Sample Initial Psychiatric Interview for Schizophrenia) | |
| Objective | Vital Signs: WNL Temp: Most recent vital signs: BP 161/99, HR 91, Temp 97.5, RR 18, O2 99% No blood work is currently available. MSE: Mental Status Exam: Orientation – oriented to person, place, and time Appearance – appeared stated age, grooming moderately neglected, eye contact good behavior – composed, concerned Attitude – calm, cooperative Rapport – candid and easy to connect with Speech and Language – clear, normal rate, rhythm, and volume Mood – moderately depressed Affect – mood congruent Thought Processes/Associations – logical and goal focused Thought Content – significant delusional thinking noted relating everyday noises to other issues per HPI Suicidal/Homicidal Ideation – no suicidal or homicidal ideation Cognitive – not formally tested but grossly within normal limits Concentration – within normal limits Abstraction – good Serial Sevens – no errors Memory – within normal limits MMSE – 30/30 Insight – fair Judgment – good Pro-essays.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us (Sample Initial Psychiatric Interview for Schizophrenia) |
| This is where the “facts” are located. Vitals, **Physical Exam (if performed, will not be performed every visit in every setting) Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results. | |
| Assessment | DSM5 Diagnosis: with ICD-10 codes Schizophrenia Paranoid type (295.30: Paranoid type-Confirmed According to Patel et al. (2014), schizophrenia is a complex mental disorder that clinically manifests with various symptoms like hallucinations and delusions. Its onset age is usually 16 to 45 years. The patient continues to display an active phase of schizophrenia but with significant improvement like being suspicious of others’ intentions, withdrawing from family and friends, and seeing things that only he can see. Other audiovisual hallucinations include hearing conspiratorial voices and tasting strange sells in ordinary foods. All these symptoms were used to confirm a diagnosis of schizophrenia – paranoid type. Bipolar Disorder Refuted Bipolar disorder with psychotic features has symptoms that overlap with those of schizophrenia-like delusions of grandeur, paranoia, and hallucinations. However, bipolar disorder is out because its patients experiences episodes of mania and depression separated by periods of relative stability (Salagre et al., 2020). However, this was not the case with A.B. Schizoaffective disorder: Refuted Schizo affective disorder was ruled out on the basis of its prominence. Patients suffering from schizoaffective disorder a mood disorders, and since they do not experience psychotic features it was used to refute this Diagnosis (Griswold et al., 2014). Pro-essays.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us (Sample Initial Psychiatric Interview for Schizophrenia) |
| Include your findings, Diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment. Informed Consent Ability | |
| Plan (Note some items may only be applicable in the inpatient environment) Pro-essays.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us (Sample Initial Psychiatric Interview for Schizophrenia) | Treatment plan The treatment entails having the patient continue with Abilify medication at the current dosage. The plan also incorporates non-pharmacological treatment through CBT and compliance therapy. Patient education will also integrate ways of managing stress and taking the other medications to treat and manage the comorbidities of T2DM and hypertension. The patient is scheduled to come for a follow-up visit after four weeks. Referral to an endocrinologist and a cardiologist will be considered if blood sugar levels and hypertension are poorly controlled. |
References
Griswold, K. S., Del Regno, P. A., & Berger, R. C. (2015). Recognition and differential Diagnosis of psychosis in primary care. American family physician, 91(12), 856-863.
Pro-essays.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us (Sample Initial Psychiatric Interview for Schizophrenia)
Patel, K. R., Cherian, J., Gohil, K., & Atkinson, D. (2014). Schizophrenia: overview and treatment options. Pharmacy and Therapeutics, 39(9), 638.
Salagre, E., Grande, I., Vieta, E., Mezquida, G., Cuesta, M. J., Moreno, C., … & Bernardo, M. (2020). Predictors of bipolar disorder versus schizophrenia diagnosis in a multicenter first psychotic episode cohort: baseline characterization and a 12-month follow-up analysis. The Journal of Clinical Psychiatry, 81(6), 15097.
Pro-essays.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us (Sample Initial Psychiatric Interview for Schizophrenia)
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