What recommendations can a PMHNP make for therapy and referral follow-up for a geriatric psychiatric patient?

  

Please see attachments
Submit a Problem-Focused SOAP note here for grading. You must use an actual patient from your clinical practicum. Review the rubric for more information on how your assignment will be graded.Please use a psychiatric patient (example of diagnosis GAD, MDD, PTSD).
Patient has to be geriatric patient older than 66 years old

PMHNP Problem-Focused SOAP Note

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(Use this template for this Assignment)

Demographic Data

Patient age and Patients gender identity
MUST BE HIPAA compliant.

Subjective

Chief Complaint (CC):

Place the patients CC complaint in Quotes

History of Present Illness (HPI):

Reason for an appointment today.

The events that led to hospitalization or clinic visits today.
Include symptoms, relieving factors, and past compliance or non-compliance with medications
Any adverse effects from past medication use
Sleep patterns number of hours of sleep per day, early wakefulness, not being able to initiate sleep, not able to stay asleep, etc.
Suicide or homicide thoughts present
Any self-care or Activity of Daily Living (ADL) such as eating, drinking liquids, self-care deficits or issues noted?
Presence/description of psychosis (if psychosis, command or non-command)

Past Psychiatric History (PSH):

Past psychiatric diagnoses
Past hospitalizations
Past psychiatric medications use
Any non-compliance issues in the past?
Any meds that didnt work for this patient?

Family History of Psychiatric Conditions or Diagnoses:

Mother/father, siblings, grandparents, or
direct relatives

Social History:

Include nutrition, exercise, substance use (details of use), sexual history/preference, occupation (type), highest school achievement, financial problems, legal issues, children, history of personal abuse (including sexual, emotional, or physical).

Allergies:

to medications, foods, chemicals, and other.

Review of Systems (ROS)(Physical Complaints):

Any physical complaints by body system? (Respiratory, Cardiac, Renal, etc.)

Objective

Mental Status Exam:

This is not physical exam.
Mini-Mental Status Exam (MMSE) Full exam

Assessment (Diagnosis)

Differentials

Two (
2) differential diagnoses with ICD-10 codes.

Must include rationale using DSM-5 Criteria (
Required)

Why didnt you pick these as a major diagnosis?

Working Diagnosis

Final or working diagnosis (
1), with ICD-10 code.

Must include rationale using DSM-5 criteria required Which symptoms/signs in the DSM-5 the patient matches mostly)

Plan

Treatment Plan (Tx Plan):

Pharmacologic: Include full information for each medication(s) prescribed
Refill Provided: Include full information for each medication(s) refilled

Patient Education:

including specific medication teaching points
Was risk versus benefit of current treatment plan addressed for meds or treatment
Risk versus benefit of non-FDA approved for working diagnosis Off-label use of medication education to patient addressed?

Prognosis:

Make Decision for prognosis: Good, Fair, Poor
Provide brief statement lending support

for
or

against
the decided prognosis.

Therapy Recommendations:

Type(s) of therapy recommended.

Referral/Follow-up:

Did you recommend follow-up with Psychiatrist, PCP, or other specialist or healthcare professionals?
When is the subsequent follow-up?
Include rationale for the F/U recommendation or referral.

Reference(s):

Include American Psychological Association (APA) formatted references.
Include a reference from the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) or the accompanying Desk Reference of Diagnostic Criteria from DSM-5.
Minimum 2 references are required. PMHNP SOAP Note Rubric

Criteria

Ratings

Pts

S

(Subjective)

10points

Accomplished

Symptom analysis is well organized in a SOAP format, with C/C, Past Psychiatric Hx, Social Hx, and other pertinent past and current diagnostic details.

SOAP Note is complete, concise, relevant with no extraneous data.

6 points

Satisfactory

Symptom analysis is well organized in a SOAP format, with C/C, Past Psychiatric Hx, Social Hx, and other pertinent past and current diagnostic details.

Some extraneous data present with 1 minor data point missing.

4 points

Needs Improvement

Symptom analysis is not well organized or presented in a varied format. Required data is missing.

There is too much extraneous data present or 2-3 minor data points are missing.

0points

Unsatisfactory

Symptom analysis is inadequate and is not organized. Objective or other data is mixed into the subjective data.

Important data is missing.

10 pts

O

(Objective)

10points

Accomplished

Mental Status Exam is complete, concise, well-organized, and well-written. Includes pertinent psychiatric information. Organized by MSE list format.

No extraneous information is included.

6points

Satisfactory

Mental Status Exam is partially incomplete, organized, and satisfactorily written. Includes pertinent psychiatric information with additional extraneous information included.

Somewhat organized in MSE list format.

4 points

Needs Improvement

Mental Status Exam is incomplete, loosely organized with improvements required. Relevant psychiatric information is omitted.

0points

Unsatisfactory

Mental Status Exam is absent, disorganized in presentation, adheres to no specific format, or grossly omits relevant or pertinent psychiatric information.

10 pts

A

(Assessment)

10points

Accomplished

Diagnosis and Differential Dx are correct with DSM-5 code(s) and supported by subjective and objective data.

Includes: 1 working Dx and 2 Differential Dx.

6points

Satisfactory

Diagnosis and Differential Dx are correct with DSM-5 code(s) and mostly supported by subjective and objective data.

Missing at least one (1) pertinent differential diagnosis not listed according to subjective and objective data. Working diagnosis is correct.

4 points

Needs Improvement

Diagnosis and Differential Dx are correct with DSM-5 code(s) and mostly supported by subjective and objective data.

Missing up to two (2) pertinent differential diagnoses based on subjective and objective data presented. Or differential diagnoses are adequate with an incorrect working diagnosis.

0points

Unsatisfactory

All diagnoses (working diagnosis and differential diagnoses) are incorrect or is missing based on the subjective and objective data presented.

10 pts

P

(Plan)

10points

Accomplished

Plan is well-organized, complete, evidence-based, and patient-centric. Fully addresses each diagnosis and is individualized to the specific patient.

*Plan requirements: prescribed medications, if any; explanation of off-label medication use, if prescribed; risks and benefits of medications identified; therapy recommendations; patient education; referral/follow-up; and health maintenance.

6 points

Satisfactory

Plan is organized, complete, evidence-based and patient-centric. Fully addresses each diagnosis and is individualized to the specific patient.

Plan is missing 1-2 of the required items.

4 points

Needs Improvement

Plan is less organized, is not based on evidence. Fails to address each diagnosis sufficiently or is not individualized or patient-centric

Plan is missing more than 2 of the required items.

0points

Unsatisfactory

Plan is disorganized, absent, or is missing all the required items.

10 pts

Total

40 pts

Introduction:

The PMHNP Problem-Focused SOAP note is an essential tool in psychiatric care that is highly necessary for professionals to create a detailed record of their patient’s health. This form is essential for the practitioner to understand the patient’s history, gather subjective and objective information, conduct a diagnosis, and provide a treatment plan. It also helps in providing a referral or follow-up, which ensures continuity of care. The following article will explore the elements of a PMHNP Problem-Focused SOAP note, which is required for geriatric patients older than 66 years with a psychiatric diagnosis of GAD, MDD, or PTSD.

Description:

As a mental health practitioner, it is imperative to have a standardized method of recording patients’ details and medical history. A PMHNP Problem-Focused SOAP note is a standardized format that mental health practitioners follow to ensure that they have documented all the necessary information about their patients. The note is broken down into several sections, including demographic data, subjective chief complaints, history of present illness, past psychiatric history, family history of psychiatric conditions, social history, allergies, review of systems, and much more. This article will focus on these essential sections of the PMHNP Problem-Focused SOAP note and explain why it is necessary to include these sections in the SOAP note. In addition, the article will look at how to formulate a diagnosis using DSM-5 criteria, create a treatment plan, and provide therapy recommendations and follow-up care. All elements of the PMHNP Problem-Focused SOAP note form part of the rubric the practitioner must follow in taking care of the patient in question.

Objectives:
1. Identify the patient’s demographic data, including age and gender identity.
2. Evaluate the patient’s subjective chief complaint and history of present illness.
3. Assess the patient’s past psychiatric history, including diagnoses and medications.
4. Analyze the patient’s family history of psychiatric conditions or diagnoses.
5. Investigate the patient’s social history, including nutrition, exercise, substance use, occupation, and history of personal abuse.
6. Review the patient’s physical complaints by body system.
7. Conduct a mental status exam, including a mini-mental status exam.
8. List two differential diagnoses with ICD-10 codes and rationale using DSM-5 criteria.
9. Choose a final or working diagnosis with ICD-10 code and rationale using DSM-5 criteria.
10. Develop a treatment plan, including pharmacologic and patient education.
11. Describe the prognosis, including a brief statement supporting the decision.
12. Recommend therapy types and follow-up with healthcare professionals.
13. Include APA-formatted references and DSM-5.

Learning Outcomes:
1. Develop an understanding of psychiatric SOAP note documentation using a geriatric patient over 66 years old with diagnoses of GAD, MDD, PTSD.
2. Gain an understanding of how to complete a Problem-Focused SOAP note.
3. Learn to analyze patient’s history of present illness, including symptoms, relief, and medication history details.
4. Understand the significance of the patient’s past psychiatric history, including diagnoses, hospitalizations, and medication history.
5. Develop an awareness of the patient’s family history of psychiatric conditions or diagnoses, social history, allergies, and physical complaints.
6. Learn to conduct a mental status exam, including a mini-mental status exam.
7. Learn to list two differential diagnoses and rationale using DSM-5 criteria.
8. Develop the ability to choose final or working diagnosis with ICD-10 code and rationale using DSM-5 criteria.
9. Learn to develop a treatment plan, including pharmacologic and patient education.
10. Learn to describe prognosis with a brief statement supporting the decision.
11. Gain an understanding of therapy types and follow-up with healthcare professionals.
12. Develop the ability to include APA-formatted references and DSM-5.

Suggested Resources/Books:

1. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
2. Geriatric Mental Health Care: A Treatment Guide for Health Professionals by Gary J. Kennedy and Stephen J. Bartels
3. Clinical Handbook of Geriatric Psychopharmacology by Sandra A. Jacobson and Rajesh R. Tampi
4. Geriatric Psychiatry Basics by Harry C. Sax and Thomas W. Meeks
5. Helping Older People with Anxiety: A Practical Guide by Arthur H. Bell and Naomi M. Simon

Similar Asked Questions:

1. How do you diagnose and treat depression in geriatric patients?
2. What are common psychiatric disorders in older adults?
3. How do you manage medication non-compliance in geriatric patients with psychiatric conditions?
4. What are the potential risks and benefits of prescribing psychotropic medications to older adults?
5. How do you address suicidal ideation in geriatric patients during treatment?

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