Open Always
Email: support@globalcompose.com Call Now! +1-315 515-4588
Open Always
Email: support@globalcompose.com Call Now! +1-315 515-4588

NURU-645 Various Note Instructions

Assignment Writing Help

This assignment question was recently posted by one of our customers and shared with our professional writers. If you are looking for assignment help on this topic or similar topic, click on ORDER NOW button to submit your details. Once we have your order details, your assignment will be assigned to one of our best writers, who will then proceed to write your paper and deliver it within your specified deadline. Thank you for choosing us today!

NURU-645 Various Note Instructions

NURU-645 Various Note Instructions

(50 Points – each)

 

Follow-up Note, Soap Note, Transfer Summary, Discharge Summary

 

The purpose of these assignments are to allow the student to learn how to do various types of notes that the PMHNP might be called upon to write in the course of their career.  There are many others but here are some of the most common ones we are asked to write. This provides the student with feedback from their instructor as they build towards having the knowledge to write these types of notes when called upon to do so because you will do each type of note twice. This allows the student to concentrate on each different type separately.  You will use a different age group patient for each note.  For Example: If you do a SOAP note on a child then your second SOAP note cannot be on a child, it must be on one of the other 3 age groups. Information needed to complete these notes will be gleaned from a patient interview, chart review and possibly family input.  Try to use a patient that can supply most of the information you need so that you may only need some information from the chart or family. Do not include any identifying data. No names, no locations. These assignments will be submitted as a Word document into the Blackboard assignment links.

 

 

SOAP NOTE

 

A SOAP note for psychiatry is a little different than a SOAP note for a medical patient, but the basic format and premise is the same.  It is a communication between the treating clinician and the next treating clinician as well as other members of the care team. It is also something that the insurance company or payor source may want to look at to determine if the patient requires this level of care. A SOAP note is a part of the Patient care Documentation (Chart), a legal document, and is to be treated as such. It is not the initial documentation on a patient, it is after the patient has been seen and an initial psychiatric evaluation has been done.

 

This is a pretty good example for you to use for preparing a SOAP NOTE. If your facility uses one you like better, that is fine. Following the information gleaned from a patient interview, a chart review; upload your note to Blackboard as directed.

 

 

SOAP NOTES:

Date and Time

Name and Credentials of person writing this note: 

ALSO LIST MEDS AND DOSES on a separate sheet as if on a MAR

Significant Events:   Over past 24 hours

Subjective (S):     Use the patient’s own words as much as possible  

  • Vegetative symptoms (sleep, appetite, concentration/energy, anxiety, etc.)
  • Patient’s complaints, pain, medication side effects
  • Requests

 

Objective (O): 

  • Vital Signs
  • Physical Exam (if pertinent, or new changes – rash, etc.)
  • Labs (admit labs of first day, new results, or new labs ordered)
  • Studies (CXR, ECG, US, neuropsychological testing, etc.)

 

MENTAL STATUS EXAM (MSE):

            Appearance        – describe hygiene, clothing and appropriateness, grooming

            Behavior               – posture, movement, psychomotor agitation/retardation, catatonia

            Speech                 – rate, rhythm, volume, prosody, latency, pressured, content (real words?)

            Mood                – what the patient says, how they are feeling (put in “quotes”)

            Affect                    – your description of how patient feels

            Thought Process – organization, tight, linear, logical, perseverance, tangential, circumferential

            Thought Content   – SI/HI, A/VH, delusions, paranoia, thought insertion, thought blocking,

                                                    special powers, grandeur, anxiety, flashbacks, nightmares, craving

            Insight                   – how well do they understand the situation? Poor, Fair, or Good

               Judgment              – how well is their decision making?  Poor, Fair, or Good

            Cognition               – MMSE score, A&O x 3, grossly intact

Assessment (A):  1-2 sentence summary of

  • Patient profile: age, M/F, race, occupation, marital status, significant characteristics (IVDU, pregnant)
  • Diagnosis (may include differential)
  • Prognosis
  • Treatment and tolerance / side effects/ improvement
  • Diagnosis: Psychiatric and Medical

 

Plan (P):       List by diagnosis or problem (medication strategy, planned tests, social work issues,

                         discharge plans)

  1. Major Depressive Disorder
  • Start XXXX PO qd
  • Schedule outpatient appointment with Dr. Psychiatrist
  • (Attend psychoeducation groups, attend process groups, etc)

SIGN YOUR NAME (print name)

 

Rubric

 

Exemplary

 

Proficient

 

Developing

 

Emerging

 

Absent

 

 

5

4

3

2

0

Demographics,

Med Sheet,

24 hour significant events present

5 points

Complete

Appropriate.

Incomplete

Appropriate

Complete

Identifying Data Present, another section missing

 

Incomplete

Identifying Data Present,

Another section missing

 

None present

 

Exemplary

 

Proficient

 

Developing

 

Emerging

 

Absent

 

 

10

8

6

4

0

Subjective

10 points

Complete

Appropriate for this section

 

Incomplete

Appropriate for this section

 

Complete

Not all appropriate for this section

 

Incomplete

Not all appropriate for this section

 

None present

 

Exemplary

 

Proficient

 

Developing

 

Emerging

 

Absent

 

 

10

8

6

4

0

Objective

10 points

Complete

Appropriate for this section

 

Incomplete

Appropriate for this section

 

Complete

Not all appropriate for this section

 

Incomplete

Not all appropriate for this section

 

None present

 

Exemplary

 

Proficient

 

Developing

 

Emerging

 

Absent

 

 

10

8

6

4

0

Assessment

10 points

Complete

Appropriate for this section

 

Incomplete

Appropriate for this section

 

Complete

Not all appropriate for this section

 

Partially complete

Not all appropriate for this section

 

None present

 

Exemplary

 

Proficient

 

Developing

 

Emerging

 

Absent

 

 

10

8

6

4

0

Plan

10 points

Complete

Appropriate for this section

 

Incomplete

Appropriate for this section

 

Complete

Not all appropriate for this section

 

Partially complete

Not all appropriate for this section

 

None present

 

Exemplary

 

Proficient

 

Developing

 

Emerging

 

Absent

 

 

5

4

3

2

0

Professional

Presentation

5 points

Complete

And professionally presented

Incomplete but

Professionally presented

Complete

But needs assistance with grammar or organization

 

Incomplete and not professionally presented

 

Not professionally done

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Academic Writing Help

All writing formats, 24/7 customer support via live chat, email or phone number, and timely delivery guaranteed.

Are you looking for homework writing help? Click on Order Now button below to Submit your assignment details.

Homework Writing Help
We Can Help you with this Assignment right now!

Are you looking for homework writing help on this topic? This question was posted by one of our client seeking homework help.  If you are therefore looking for an assignment to submit, then click on ORDER NOW button or contact us today. Our Professional Writers will be glad to write your paper from scratch, and delivered within your deadline. Perfect choice for your excellent grades! www.globalcompose.com.

 

We ensure that assignment instructions are followed, the paper is written from scratch. If you are not satisfied by our service, you can either request for refund or unlimited revisions for your order at absolutely no extra pay. Once the writer has completed your paper, the editors check your paper for any grammar/formatting/plagiarism mistakes, then the final paper is sent to your email.

Privacy| Confidentiality

We do not share your personal information with any company or person. We have also ensured that the ordering process is secure; you can check the security feature in the browser. For confidentiality purposes, all papers are sent to your personal email. If you have any questions, contact us any time via email, live chat or our phone number.

Our Clients Testimonials

  • I appreciate help on the assignment. It was hard for me but am good to go now

    Impact of pollution on Environment
  • Am happy now having completed the very difficult assignment

    Creative Message Strategies
  • Your writer did a fine job on the revisions. The paper is now ok

    Ethics: Theory and Practice
  • The paper was so involving but am happy it is done. Will reach you with more assignments

    Title: Privatization in or of America
  • I expected perfection in terms of grammar and I am happy. Lecturer is always on our head but was pleased with my paper. Once again, thanks a lot

    Title: Bundaberg Inquiry
  • The paper looks perfect now, thank to the writer

    Health Care Systems
  • You helped me complete several other tasks as you handled paper. wonna thank you

    Critique Paper on Political Change

Get more from us…

Would you like this sample paper to be sent to your email or would you like to receive weekly articles on how to write your assignments? You can simply send us your request on how to write your paper and we will email you a free guide within 24-36 hours. Kindly subscribe below!

Email Address: support@globalcompose.com