Psychopharma Week 6 Discussion Psychopharma Week 6 Discussion The PMHNP SOAP note is a tool utilized to guide clinical reasoning to assess, diagnosis, and devel

Psychopharma Week 6 Discussion

Psychopharma Week 6 Discussion

The PMHNP SOAP note is a tool utilized to guide clinical reasoning to assess, diagnosis, and develop a treatment plan for a patient based on information presented and current evaluation of the patient. These notes serve as an important source of information about the health status of the patient and can be used to communicate this status to other health care professionals.


Review the following resources: (See attachments)
SOAP Note Presentation (PowerPoint)
SOAP Note Presentation Transcript
SOAP Note Template (Word)
Complete the SOAP Note Questionnaire and submit to this assignment.
Background: I am currently enrolled in the Psych Mental Health Nurse Practitioner Program, I am a Registered Nurse, and I work in a Psychiatric Hospital.

Consulting the Answer Key, please answer the following questions:

1. What does the S stand for in the SOAP note format?

2. What information is contained in the S section?

3. What does the O stand for in the SOAP note format?

4. What information is contained in the O section?

5. What does the A stand for in the SOAP note format?

6. What information is contained in the A section?

7. What does the P stand for in the SOAP note format?

8. What information is contained in the P section?

9. What is the purpose of the PMHNP Soap Note?

10. Which section contains information that can be observed or measured?

11. Which section contains the differential diagnoses?

12. Which section contains the Mental Status Exam (MSE)?

Answer key:

These terms may be applicable to more than one question.

· Subjective

· Guides clinical reasoning, diagnosis, and treatment decisions; facilitates communication among providers, tracks progress

· Objective

· Chief complaint, demographic information, HPI, PMH, Social History

· Plan

· Assessment

· VS, ROS, MSE, labs, screening assessments, “facts”

· Diagnosis and differential diagnoses, DSM-5 criteria, and potential treatment options

· Specific instructions for medications and dosing, lab work ordered, referrals, therapy recommendations, follow up

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