NRNP 6655 DQ Focused SOAP Note and Patient Case Presentation

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NRNP 6655 DQ Focused SOAP Note and Patient Case Presentation

NRNP 6655 DQ Focused SOAP Note and Patient Case Presentation

What do I have to do? When do I have to do it?

Review your Learning Resources. Days 1–7

Assignment 1: Clinical Hour and
Patient Logs

Record your clinical hours and patient
encounters in Meditrek by Day 7.

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Assignment 2: Focused SOAP Note
and Patient Case Presentation Submit by Day 7.

Introduction
Consider the experiences you have had thus far, either in the healthcare workplace or at
your practicum site. As you likely know, a nurse’s job does not begin and end with one-to-
one patient contact. It includes meetings, documentation, trainings, and collaboration. In
particular, the nurse is a member of an interdisciplinary team and must use oral and
written communication to inform others of a patient’s status. A central skill of advanced
practice nursing, then, is the ability to present a patient’s history, symptoms, diagnosis, and
treatment plan to relevant parties involved in treatment.
This week, in addition to your Meditrek tracking, you will develop a focused SOAP note
and video case presentation on one of the patients you have examined in your clinical
practicum.
Learning Objectives
Students will:
 Describe clinical hours and patient encounters
 Assess patients across the lifespan in mental health settings
 Formulate differential diagnoses for patients across the lifespan in mental health
settings
 Develop plans of care for patients across the lifespan in mental health settings
 Advocate health promotion and patient education strategies across the lifespan
 Develop a case study presentation based on a clinical patient

Learning Resources

Required Readings (click to expand/reduce)

Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
 Section II. The Psychiatric History (Chapters 14–18)
 Section III. Interviewing for Diagnosis: The Psychiatric Review of Symptoms
(Chapters 23–24)

Lorberg, B., Davico, C., Martsenkovskyi, D., & Vitiello, B. (2019). Principles in using
psychotropic medication in children and adolescents. 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/content/uploads/A.7-Psychopharmacology-2019.1.pdf

Meditrek
https://edu.meditrek.com/Default.html
Note: Use this link to log into Meditrek to report your clinical hours and
patient encounters.

Document: Focused SOAP Note Template (Word document)

Document: Focused SOAP Note Exemplar (Word document)

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