Each student will create a focused SOAP note or PowerPoint presentation about Infant or Toddler (Under Age 6). SOAP is an acronym
Each student will create a focused SOAP note or PowerPoint presentation about Infant or Toddler (Under Age 6). SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive psychiatric SOAP note or PowerPoint is to be written using the attached template below. Do not provide a voiceover or video for the PowerPoint. Only the information asked in the video will be used for grading.
S =
Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS). Click here Links to an external site.for more details
O =
Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; and Mental Status Exam
A =
Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes
P =
Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up
Other: Incorporate current clinical guidelines NIH Clinical Guidelines Links to an external site.or APA Clinical Guidelines Links to an external site., research articles, and the role of the PMHNP in your presentation.
Psychiatric Assessment of Infants and ToddlersLinks to an external site.
Psychiatric Assessment of Children and AdolescentsLinks to an external site.
Reminder: It is important that you complete this assessment using your critical thinking skills. You are expected to synthesize your clinical assessment, formulate a psychiatric diagnosis, and develop a treatment plan independently. It is not acceptable to document “my preceptor made this diagnosis.” An example of the appropriate descriptors of the clinical evaluation is listed below. It is not acceptable to document “within normal limits.”
Graduate Mental Status Exam GuideDownload Graduate Mental Status Exam Guide
Submission Instructions:
In addition to the video demonstrating proficiency in completing a comprehensive psychiatric evaluation, students must upload a comprehensive written submission.
The written submission should be limited to PowerPoint 10-12 slides or a comprehensive psychiatric note and include all sections of the SOAP note listed above.
The comprehensive psychiatric examination is original work and logically organized, formatted, and cited in the current APA style, including citation of references. Incorporate a minimum of four current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work. Journal articles and books should be referenced according to APA style, 7th Edition (the library has a copy of the APA Manual).
Students must wear their lab coats, display their STU or other identification, and conduct the video in a professional setting, or the presentation will not be graded.
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