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)?
These terms may be applicable to more than one question.
· Guides clinical reasoning, diagnosis, and treatment decisions; facilitates communication among providers, tracks progress
· Chief complaint, demographic information, HPI, PMH, Social History
· 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
You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.
Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.
Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.
The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.
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