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read what is attached and soap note will be om a 15 year old who has bipolar and scjizophernia 1. Compose a written comprehensive psychiatric

April 22, 2025

read what is attached and soap note will be om a 15 year old who has bipolar and scjizophernia

1. Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.

2. Upload your completed comprehensive psychiatric evaluation as a Word doc. Scanned PDFs will not be accepted.

·
For the Comprehensive Psychiatric Evaluation Presentation Assignment: You will need to get it signed by your preceptor for the presentation (actual signature, not electronically typed).

Step 2: Each student will create a focused SOAP note video presentation in the next assignment. See

Comprehensive Psychiatric Evaluation Presentation 1
for more details.

SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.

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)

O =

Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam, (Focused), 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 GuidelinesLinks to an external site.
or

APA Clinical GuidelinesLinks to an external site.
, research articles, and the role of the PMHNP in your evaluation.

atatched is the soap note template use apa 7 the dition

>Nursing homework help

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