Category: Nursing

  • [Solved] Discussion Post

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    Discuss about a 65-year-old white female with GOUT Describe your clinical experience for this week: – Did you face any challenges, any success? If so, what were they? – Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible dif…

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    Assignment Prompt & Instructions

    Discuss about a 65-year-old white female with GOUT
    Describe your clinical experience for this week:
    – Did you face any challenges, any success? If so, what were they?
    – Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differential diagnosis with rationales.
    – Mention the health promotion intervention for this patient.
    – What did you learn from this week's clinical experience that can beneficial for you as an advanced practice nurse?
    – Support your plan of care with the current peer-reviewed research guideline.

  • [Solved] Nursing assignment 12

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    – ## assignment12.docx **## assignment12.docx** Please answer the following 4 questions (writing prompts) using an in-depth analysis method. "An in-depth analysis essay probes beyond superficial layers to examine the components of an object or a topic of interest. As you brainstorm ideas, you improv…

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    Assignment Prompt & Instructions

    – ## assignment12.docx

    **## assignment12.docx**

    Please answer the following 4 questions (writing prompts) using an in-depth analysis method.

    "An in-depth analysis essay probes beyond superficial layers to examine the components of an object or a topic of interest. As you brainstorm ideas, you improve your perception and hone your critical thinking skills, which will help you write a focused and comprehensive in-depth analysis essay."

    Each essay should include:

    Thoughtful and detailed writing.

    APA formatting.

    Cited references (if used)

    A minimum of 2 paragraphs in length for each writing prompt.

    Please submit a current resume.

    I just wrote some answers that I though might be helpful. You can ignore the parts you are thinking are not strong to use. And add what ever you think that can make answers thoughtful

    1.
    **Explain why you are interested in working in a community health center with medically underserved and culturally diverse patients. How and when did your interest in working with low-income populations begin?**

    Do to my background (Iran) I am naturally related to the underserved population

    Also, working at Cedars-Sinai Medical Center causes me to be exposed to a diverse patient population

    Motivation: my journey and desire to support others who face similar barriers (because I can understand them better)

    I always had this goal in my life to try to help people in any way that I can.

    2.
    **In your community, hospital, or among your friends, how do you help people that may have needs based on social determinants of health (income, access, transportation, insurance, food insecurity, literacy, non-English speaking)? What, specifically, do you think could be done to improve the care delivered to the underinsured or uninsured**.

    Translating or explaining medical information for your parents or patients with limited English proficiency. In the hospital, I always ask my coworkers if they have any patients who speak Farsi or Turkish and are not be able to speak English. I will go to their room a couple of times during that shift, introduce myself, and tell them if they need anything, just tell their nurse to call me, so I can check on them and translate everything for them.

    Among our friends, we have a family that established a church. They are helping all immigrants and underserved people who are non-English speaking, with different services such as resources and free food. I am helping them monthly with food packaging and delivery

    3.
    **Describe some of the difficulties commonly shared among culturally diverse communities that can impact physical or mental health. What methods or approaches could help bridge the healthcare gap?**

    Mental health stigma in minority groups, particularly Middle Eastern cultures.

    Limited access to preventive care due to fear, misinformation, or cost.

    Fear of judgment or misunderstanding from providers.

    Approaches to bridge gap: using community health workers, building trust through culturally sensitive care, offering interpretation services.

    4.
    **Describe cultural strengths that you recognize in minority populations that can be used for health promotion.**

    **Give an example of one way to promote health education in a minority population community**.

    5.
    **Our grant program is dedicated to educate and support grant recipients in providing educational resources that help navigate the primary clinical setting at a low-income or federally qualified health center. Share about what excites you and/or intimidates you about working in this specific medical setting.**

    Confidence: belief that your empathy, background, and training uniquely prepare you for the challenge

    **## assignment12.docx**

    Please answer the following 4 questions (writing prompts) using an in-depth analysis method.

    "An in-depth analysis essay probes beyond superficial layers to examine the components of an object or a topic of interest. As you brainstorm ideas, you improve your perception and hone your critical thinking skills, which will help you write a focused and comprehensive in-depth analysis essay."

    Each essay should include:

    Thoughtful and detailed writing.

    APA formatting.

    Cited references (if used)

    A minimum of 2 paragraphs in length for each writing prompt.

    Please submit a current resume.

    I just wrote some answers that I though might be helpful. You can ignore the parts you are thinking are not strong to use. And add what ever you think that can make answers thoughtful

    1.
    **Explain why you are interested in working in a community health center with medically underserved and culturally diverse patients. How and when did your interest in working with low-income populations begin?**

    Do to my background (Iran) I am naturally related to the underserved population

    Also, working at Cedars-Sinai Medical Center causes me to be exposed to a diverse patient population

    Motivation: my journey and desire to support others who face similar barriers (because I can understand them better)

    I always had this goal in my life to try to help people in any way that I can.

    2.
    **In your community, hospital, or among your friends, how do you help people that may have needs based on social determinants of health (income, access, transportation, insurance, food insecurity, literacy, non-English speaking)? What, specifically, do you think could be done to improve the care delivered to the underinsured or uninsured**.

    Translating or explaining medical information for your parents or patients with limited English proficiency. In the hospital, I always ask my coworkers if they have any patients who speak Farsi or Turkish and are not be able to speak English. I will go to their room a couple of times during that shift, introduce myself, and tell them if they need anything, just tell their nurse to call me, so I can check on them and translate everything for them.

    Among our friends, we have a family that established a church. They are helping all immigrants and underserved people who are non-English speaking, with different services such as resources and free food. I am helping them monthly with food packaging and delivery

    3.
    **Describe some of the difficulties commonly shared among culturally diverse communities that can impact physical or mental health. What methods or approaches could help bridge the healthcare gap?**

    Mental health stigma in minority groups, particularly Middle Eastern cultures.

    Limited access to preventive care due to fear, misinformation, or cost.

    Fear of judgment or misunderstanding from providers.

    Approaches to bridge gap: using community health workers, building trust through culturally sensitive care, offering interpretation services.

    4.
    **Describe cultural strengths that you recognize in minority populations that can be used for health promotion.**

    **Give an example of one way to promote health education in a minority population community**.

    5.
    **Our grant program is dedicated to educate and support grant recipients in providing educational resources that help navigate the primary clinical setting at a low-income or federally qualified health center. Share about what excites you and/or intimidates you about working in this specific medical setting.**

    Confidence: belief that your empathy, background, and training uniquely prepare you for the challenge

  • [Solved] disc 6 health policy

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    \ disc6healthpolicy.png](https://www.sweetstudy.com/files/disc6healthpolicy-png "disc6healthpolicy.png") \ rubricforhealthpolicy.png](https://www.sweetstudy.com/files/rubricforhealthpolicy-png-10332533 "rubricforhealthpolicy.png")

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    Assignment Prompt & Instructions

    \
    disc6healthpolicy.png](https://www.sweetstudy.com/files/disc6healthpolicy-png "disc6healthpolicy.png")
    \
    rubricforhealthpolicy.png](https://www.sweetstudy.com/files/rubricforhealthpolicy-png-10332533 "rubricforhealthpolicy.png")

  • [Solved] SOAP Note

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    Executive Solution Overview

    I need to come up with a SOAP note following this specific algorithm. Instructions will be provided.

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    Assignment Prompt & Instructions

    I need to come up with a SOAP note following this specific algorithm. Instructions will be provided.

  • [Solved] Mod.6 HealthP DiscussionReply

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    Executive Solution Overview

    ***CASE STUDIES ATTACHED*** You should respond to both discussions separately–with constructive literature material- extending, refuting/correcting, or adding additional nuance to their posts. Minimum 150 words each reply with references under each reply. Incorporate a minimum of 2 current (p…

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    Assignment Prompt & Instructions

    ***CASE STUDIES ATTACHED***
    You should respond to both discussions separately–with constructive literature material- extending, refuting/correcting, or adding additional nuance to their posts.
    Minimum 150 words each reply with references under each reply.
    Incorporate a minimum of 2 current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work. Journal articles should be referenced according to the current APA style (the online library has an abbreviated version of the APA Manual).
    \
    Healthpmod6reply.docx](https://www.sweetstudy.com/files/healthpmod6reply-docx "Healthpmod6reply.docx")

  • [Solved] smart goals

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    Executive Solution Overview

    one atached is instuctiosn on smart goals the ppt attahced is the smart goals you will base if off – ## smartgoalsfinisbedmodule1eddited.pptx – smartgoalsmoduile6instructions.docx **## smartgoalsfinisbedmodule1eddited.pptx** Smart Goals Improve Psychotherapy Competencies with Patients Specific: I ai…

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    Assignment Prompt & Instructions

    one atached is instuctiosn on smart goals the ppt attahced is the smart goals you will base if off

    – ## smartgoalsfinisbedmodule1eddited.pptx

    – smartgoalsmoduile6instructions.docx

    **## smartgoalsfinisbedmodule1eddited.pptx**

    Smart Goals

    Improve Psychotherapy Competencies with Patients

    Specific: I aim to improve my capacity to provide effective psychotherapy, with an emphasis on CBT and supportive therapy techniques.

    Measurable: My preceptor will provide me with weekly feedback, and I will monitor my progress in my clinical logs.

    Achievable: With supervision, I will use psychotherapy methods in at least one session each week.

    Relevant: For my growth as a PMHNP, it is crucial to enhance therapeutic skills.

    Timely: By the conclusion of week 8 of this clinical term, I will have accomplished this.

    Wheeler, 2020

    This objective aims to enhance my skills in delivering psychotherapy, particularly with techniques such as CBT and supportive therapy. My goal is to boost my confidence in session management, addressing client needs, and real-time application of theoretical knowledge. I will think back on every session and get weekly feedback from my preceptor to help me grow. At the end of the term, I hope to feel more secure in my identity as a future PMHNP-psychotherapist.

    2

    Articulate 5 DSM-5 Diagnoses

    Specific: My goal is to accurately develop a minimum of five DSM-5 diagnoses throughout my clinical rotations.

    Measurable: My preceptor will review and confirm the accuracy of the diagnoses.

    Achievable: This can be reached with ongoing exposure to patient cases and supervision.

    Relevant: A fundamental competency and objective of the course for PMHNPs is diagnostic accuracy.

    Timely: The midpoint of the clinical term (week 6) will see the goal achieved.

    American Nurses Credentialing Center, 2023

    This objective is aimed at ensuring that patients are accurately diagnosed in accordance with the DSM-5 framework. I aim to have made accurate diagnoses for at least five patients by the midpoint of the term. Preceptor confirmation allows for measuring the goal. It is attainable, as I will be exposed to more cases each week and will have the opportunity to review the criteria and apply what I’ve learned. As a fundamental skill for PMHNPs, diagnosis is in keeping with the aims of the course.

    3

    Create and Execute 3 Treatment Plans Based on Evidence

    Specific: My goal is to create and carry out a minimum of three treatment plans grounded in evidence for patients suffering from mood or anxiety disorders.

    Measurable: My preceptor will assess each plan and record the evaluations in clinical notes.

    Achievable: With regular oversight and clinical case opportunities, this can be accomplished.

    Relevant: In PMHNP practice, treatment planning is essential.

    Timely: Should be finalized by the end of week 10 of the clinical term.

    American Nurses Credentialing Center, 2023

    This objective focuses on the development and execution of three evidence-based treatment plans for patients suffering from anxiety or mood disorders. I will discuss and evaluate each plan with my preceptor. To make certain that every treatment plan conforms to best-practice standards, I will depend on academic resources and clinical guidelines. I selected this because I want to master treatment planning, which is a crucial skill, before graduation.

    4

    Improve Knowledge of Psychopharmacology

    Specific: My goal is to enhance my knowledge of psychotropic medications, especially SSRIs, stimulants, and antipsychotics.

    Measurable: I will carry out weekly medication reviews and talk about them with my preceptor.

    Achievable: My textbook, online modules, and discussions with my preceptor are among the resources.

    relevant :Core element of psychiatric nursing practice: Medication management.

    Timely: I will monitor learning progress and complete the goal by the end of the clinical term.

    Wheeler, 2020

    With this goal, I aim to enhance my understanding of psychopharmacology. I will examine important categories of medication, including SSRIs, stimulants, and antipsychotics. This will be assessed by means of medication reviews, weekly discussions with my preceptor, and self-reflection. I selected this because managing medication can seem daunting, and I aim to enhance my understanding and self-assurance in this domain.

    5

    Build Rapport with At Least 10 Patients

    Specific: My goal is to establish a successful therapeutic rapport with no fewer than 10 patients.

    Measurable: Patient feedback, preceptor notes, and clinical reflections will indicate the success of rapport-building.

    Achievable: I will apply methods of involvement, empathy, and attentive listening in every interaction with patients.

    Relevant: A strong therapeutic alliance enhances outcomes and is an essential skill for PMHNPs.

    Timely: The goal will be achieved by the end of the 12-week term.

    Wheeler, 2020

    It is vital for therapy to succeed that a good relationship with patients is developed. I aim to connect with at least 10 patients in a meaningful way, utilizing empathy, active listening, and engagement skills. Feedback and clinical documentation will reflect how strong these relationships are. I aim to achieve this goal by the end of the term. This will assist me in establishing trust and honing my therapeutic communication style.

    6

    Master Use of Screening Tools (PHQ-9, GAD-7, Vanderbilt)

    Specific: My goal is to administer and interpret at least three standardized screening tools during clinical sessions with confidence.

    Measurable: My preceptor will assess my comprehension and application of each tool via observation and chart reviews.

    Achievable: I will be able to practice these tools often during my clinical term, as they are commonly used.

    Relevant: In psychiatric evaluations, precise screening is crucial and consistent with the aims of the program.

    Timely: The completion of this goal is scheduled for week 9 of the clinical term.

    American Nurses Credentialing Center, 2023

    For this purpose, I aim to become skilled in using important screening tools such as the PHQ-9, GAD-7, and Vanderbilt forms. During patient intake or follow-up visits, I will practice using them, and my preceptor will assess how I score and interpret results. These tools are crucial for ensuring informed clinical decisions and enhancing patient outcomes.

    7

    Rehearse evaluation of suicide risk and planning for safety

    Specific: I will carry out a comprehensive suicide risk evaluation on no fewer than five patients showing signs of depression or suicidal thoughts.

    Measurable: My preceptor will review and document each assessment.

    Achievable: I will utilize the Columbia-Suicide Severity Rating Scale (C-SSRS) and safety planning templates under supervision.

    Relevant: Preventing suicide is crucial in psychiatric care, and it corresponds with the objectives of the course.

    Timely: The completion of this goal is scheduled for week 10 of the term.

    American Nurses Credentialing Center, 2023

    This aim focuses on building confidence in conducting suicide risk assessments and developing safety plans. I intend to utilize organized tools such as the Columbia-Suicide Severity Rating Scale and safety planning templates. To guarantee that my evaluations are comprehensive and suitable for the risk level of each patient, I will collaborate closely with my preceptor.

    8

    Participate in at Least 2 Family Sessions

    Specific: During my clinical rotation, I aim to observe or co-lead a minimum of two sessions focused on family therapy or psychoeducation.

    Measurable: My preceptor will keep a record of and assess attendance and participation.

    Achievable: There are opportunities for family involvement in outpatient and pediatric settings.

    Relevant: In the field of child and adolescent psychiatry, it is essential to comprehend family dynamics.

    Timely: Should be finished by the end of week 11.

    Wheeler, 2020

    I aim to acquire experience in dealing with families, particularly regarding mental health issues in children and adolescents. I will strive to attend or help lead at least two family sessions, where I will observe communication patterns and the therapist's role. This will aid me in providing better support for family systems and overall patient care.

    9

    Present 1 Case Study During Clinical Rounds

    Specific: I will present a detailed psychiatric case, along with its diagnosis and treatment plan, to my clinical team.

    Measurable: My preceptor or instructor will schedule and evaluate the presentation.

    Achievable: I will select a patient I’ve been monitoring and prepare with my preceptor’s guidance.

    Relevant: Showcasing patient cases enhances critical thinking and equips me for actual teamwork.

    Timely: The completion will occur by the end of week 12.

    Wheeler, 2020

    To achieve this goal, I intend to present a comprehensive case study during rounds. I will choose a patient I have collaborated with and provide a summary of their history, diagnosis, treatment, and response. This exercise will assist in developing my confidence regarding the articulation of clinical reasoning and communication with interdisciplinary teams.

    10

    Enhance the accuracy of documentation and charting

    Specific: I will enhance my clinical documentation by ensuring all chart entries are completed within 24 hours and obtaining weekly feedback from my preceptor.

    Measurable: The accuracy and timeliness will be monitored through the examination of chart audits and preceptor notes.

    Achievable: I will maintain structure by using EMR templates and charting checklists.

    Relevant: Safe and legal psychiatric practice relies heavily on accurate documentation.

    Timely: This will be upheld consistently over the course of the term and reviewed every two weeks.

    American Nurses Credentialing Center, 2023

    This goal pertains to clinical documentation, which is vital for continuity of care, legal precision, and effective communication. To keep organized, I will utilize checklists and EMR templates, and I will make sure to document all encounters within a 24-hour timeframe. My notes will be reviewed weekly by my preceptor for feedback.

    11

    References

    American Nurses Credentialing Center. (2023). Scope and standards of practice for psychiatric-mental health nursing.

    Wheeler, K. (2020). Psychotherapy for the Advanced Practice Psychiatric Nurse: A How-To Guide for Evidence-Based Practice (3rd ed.). Springer Publishing.

    **smartgoalsmoduile6instructions.docx**

    This file is too large to display. [View in new window](https://www.sweetstudy.com/files/smartgoalsmoduile6instructions-docx)

    **smartgoalsmoduile6instructions.docx**

    This file is too large to display. [View in new window](https://www.sweetstudy.com/files/smartgoalsmoduile6instructions-docx)

    **## smartgoalsfinisbedmodule1eddited.pptx**

    Smart Goals

    Improve Psychotherapy Competencies with Patients

    Specific: I aim to improve my capacity to provide effective psychotherapy, with an emphasis on CBT and supportive therapy techniques.

    Measurable: My preceptor will provide me with weekly feedback, and I will monitor my progress in my clinical logs.

    Achievable: With supervision, I will use psychotherapy methods in at least one session each week.

    Relevant: For my growth as a PMHNP, it is crucial to enhance therapeutic skills.

    Timely: By the conclusion of week 8 of this clinical term, I will have accomplished this.

    Wheeler, 2020

    This objective aims to enhance my skills in delivering psychotherapy, particularly with techniques such as CBT and supportive therapy. My goal is to boost my confidence in session management, addressing client needs, and real-time application of theoretical knowledge. I will think back on every session and get weekly feedback from my preceptor to help me grow. At the end of the term, I hope to feel more secure in my identity as a future PMHNP-psychotherapist.

    2

    Articulate 5 DSM-5 Diagnoses

    Specific: My goal is to accurately develop a minimum of five DSM-5 diagnoses throughout my clinical rotations.

    Measurable: My preceptor will review and confirm the accuracy of the diagnoses.

    Achievable: This can be reached with ongoing exposure to patient cases and supervision.

    Relevant: A fundamental competency and objective of the course for PMHNPs is diagnostic accuracy.

    Timely: The midpoint of the clinical term (week 6) will see the goal achieved.

    American Nurses Credentialing Center, 2023

    This objective is aimed at ensuring that patients are accurately diagnosed in accordance with the DSM-5 framework. I aim to have made accurate diagnoses for at least five patients by the midpoint of the term. Preceptor confirmation allows for measuring the goal. It is attainable, as I will be exposed to more cases each week and will have the opportunity to review the criteria and apply what I’ve learned. As a fundamental skill for PMHNPs, diagnosis is in keeping with the aims of the course.

    3

    Create and Execute 3 Treatment Plans Based on Evidence

    Specific: My goal is to create and carry out a minimum of three treatment plans grounded in evidence for patients suffering from mood or anxiety disorders.

    Measurable: My preceptor will assess each plan and record the evaluations in clinical notes.

    Achievable: With regular oversight and clinical case opportunities, this can be accomplished.

    Relevant: In PMHNP practice, treatment planning is essential.

    Timely: Should be finalized by the end of week 10 of the clinical term.

    American Nurses Credentialing Center, 2023

    This objective focuses on the development and execution of three evidence-based treatment plans for patients suffering from anxiety or mood disorders. I will discuss and evaluate each plan with my preceptor. To make certain that every treatment plan conforms to best-practice standards, I will depend on academic resources and clinical guidelines. I selected this because I want to master treatment planning, which is a crucial skill, before graduation.

    4

    Improve Knowledge of Psychopharmacology

    Specific: My goal is to enhance my knowledge of psychotropic medications, especially SSRIs, stimulants, and antipsychotics.

    Measurable: I will carry out weekly medication reviews and talk about them with my preceptor.

    Achievable: My textbook, online modules, and discussions with my preceptor are among the resources.

    relevant :Core element of psychiatric nursing practice: Medication management.

    Timely: I will monitor learning progress and complete the goal by the end of the clinical term.

    Wheeler, 2020

    With this goal, I aim to enhance my understanding of psychopharmacology. I will examine important categories of medication, including SSRIs, stimulants, and antipsychotics. This will be assessed by means of medication reviews, weekly discussions with my preceptor, and self-reflection. I selected this because managing medication can seem daunting, and I aim to enhance my understanding and self-assurance in this domain.

    5

    Build Rapport with At Least 10 Patients

    Specific: My goal is to establish a successful therapeutic rapport with no fewer than 10 patients.

    Measurable: Patient feedback, preceptor notes, and clinical reflections will indicate the success of rapport-building.

    Achievable: I will apply methods of involvement, empathy, and attentive listening in every interaction with patients.

    Relevant: A strong therapeutic alliance enhances outcomes and is an essential skill for PMHNPs.

    Timely: The goal will be achieved by the end of the 12-week term.

    Wheeler, 2020

    It is vital for therapy to succeed that a good relationship with patients is developed. I aim to connect with at least 10 patients in a meaningful way, utilizing empathy, active listening, and engagement skills. Feedback and clinical documentation will reflect how strong these relationships are. I aim to achieve this goal by the end of the term. This will assist me in establishing trust and honing my therapeutic communication style.

    6

    Master Use of Screening Tools (PHQ-9, GAD-7, Vanderbilt)

    Specific: My goal is to administer and interpret at least three standardized screening tools during clinical sessions with confidence.

    Measurable: My preceptor will assess my comprehension and application of each tool via observation and chart reviews.

    Achievable: I will be able to practice these tools often during my clinical term, as they are commonly used.

    Relevant: In psychiatric evaluations, precise screening is crucial and consistent with the aims of the program.

    Timely: The completion of this goal is scheduled for week 9 of the clinical term.

    American Nurses Credentialing Center, 2023

    For this purpose, I aim to become skilled in using important screening tools such as the PHQ-9, GAD-7, and Vanderbilt forms. During patient intake or follow-up visits, I will practice using them, and my preceptor will assess how I score and interpret results. These tools are crucial for ensuring informed clinical decisions and enhancing patient outcomes.

    7

    Rehearse evaluation of suicide risk and planning for safety

    Specific: I will carry out a comprehensive suicide risk evaluation on no fewer than five patients showing signs of depression or suicidal thoughts.

    Measurable: My preceptor will review and document each assessment.

    Achievable: I will utilize the Columbia-Suicide Severity Rating Scale (C-SSRS) and safety planning templates under supervision.

    Relevant: Preventing suicide is crucial in psychiatric care, and it corresponds with the objectives of the course.

    Timely: The completion of this goal is scheduled for week 10 of the term.

    American Nurses Credentialing Center, 2023

    This aim focuses on building confidence in conducting suicide risk assessments and developing safety plans. I intend to utilize organized tools such as the Columbia-Suicide Severity Rating Scale and safety planning templates. To guarantee that my evaluations are comprehensive and suitable for the risk level of each patient, I will collaborate closely with my preceptor.

    8

    Participate in at Least 2 Family Sessions

    Specific: During my clinical rotation, I aim to observe or co-lead a minimum of two sessions focused on family therapy or psychoeducation.

    Measurable: My preceptor will keep a record of and assess attendance and participation.

    Achievable: There are opportunities for family involvement in outpatient and pediatric settings.

    Relevant: In the field of child and adolescent psychiatry, it is essential to comprehend family dynamics.

    Timely: Should be finished by the end of week 11.

    Wheeler, 2020

    I aim to acquire experience in dealing with families, particularly regarding mental health issues in children and adolescents. I will strive to attend or help lead at least two family sessions, where I will observe communication patterns and the therapist's role. This will aid me in providing better support for family systems and overall patient care.

    9

    Present 1 Case Study During Clinical Rounds

    Specific: I will present a detailed psychiatric case, along with its diagnosis and treatment plan, to my clinical team.

    Measurable: My preceptor or instructor will schedule and evaluate the presentation.

    Achievable: I will select a patient I’ve been monitoring and prepare with my preceptor’s guidance.

    Relevant: Showcasing patient cases enhances critical thinking and equips me for actual teamwork.

    Timely: The completion will occur by the end of week 12.

    Wheeler, 2020

    To achieve this goal, I intend to present a comprehensive case study during rounds. I will choose a patient I have collaborated with and provide a summary of their history, diagnosis, treatment, and response. This exercise will assist in developing my confidence regarding the articulation of clinical reasoning and communication with interdisciplinary teams.

    10

    Enhance the accuracy of documentation and charting

    Specific: I will enhance my clinical documentation by ensuring all chart entries are completed within 24 hours and obtaining weekly feedback from my preceptor.

    Measurable: The accuracy and timeliness will be monitored through the examination of chart audits and preceptor notes.

    Achievable: I will maintain structure by using EMR templates and charting checklists.

    Relevant: Safe and legal psychiatric practice relies heavily on accurate documentation.

    Timely: This will be upheld consistently over the course of the term and reviewed every two weeks.

    American Nurses Credentialing Center, 2023

    This goal pertains to clinical documentation, which is vital for continuity of care, legal precision, and effective communication. To keep organized, I will utilize checklists and EMR templates, and I will make sure to document all encounters within a 24-hour timeframe. My notes will be reviewed weekly by my preceptor for feedback.

    11

    References

    American Nurses Credentialing Center. (2023). Scope and standards of practice for psychiatric-mental health nursing.

    Wheeler, K. (2020). Psychotherapy for the Advanced Practice Psychiatric Nurse: A How-To Guide for Evidence-Based Practice (3rd ed.). Springer Publishing.

    **smartgoalsmoduile6instructions.docx**

    This file is too large to display. [View in new window](https://www.sweetstudy.com/files/smartgoalsmoduile6instructions-docx)

    **## smartgoalsfinisbedmodule1eddited.pptx**

    Smart Goals

    Improve Psychotherapy Competencies with Patients

    Specific: I aim to improve my capacity to provide effective psychotherapy, with an emphasis on CBT and supportive therapy techniques.

    Measurable: My preceptor will provide me with weekly feedback, and I will monitor my progress in my clinical logs.

    Achievable: With supervision, I will use psychotherapy methods in at least one session each week.

    Relevant: For my growth as a PMHNP, it is crucial to enhance therapeutic skills.

    Timely: By the conclusion of week 8 of this clinical term, I will have accomplished this.

    Wheeler, 2020

    This objective aims to enhance my skills in delivering psychotherapy, particularly with techniques such as CBT and supportive therapy. My goal is to boost my confidence in session management, addressing client needs, and real-time application of theoretical knowledge. I will think back on every session and get weekly feedback from my preceptor to help me grow. At the end of the term, I hope to feel more secure in my identity as a future PMHNP-psychotherapist.

    2

    Articulate 5 DSM-5 Diagnoses

    Specific: My goal is to accurately develop a minimum of five DSM-5 diagnoses throughout my clinical rotations.

    Measurable: My preceptor will review and confirm the accuracy of the diagnoses.

    Achievable: This can be reached with ongoing exposure to patient cases and supervision.

    Relevant: A fundamental competency and objective of the course for PMHNPs is diagnostic accuracy.

    Timely: The midpoint of the clinical term (week 6) will see the goal achieved.

    American Nurses Credentialing Center, 2023

    This objective is aimed at ensuring that patients are accurately diagnosed in accordance with the DSM-5 framework. I aim to have made accurate diagnoses for at least five patients by the midpoint of the term. Preceptor confirmation allows for measuring the goal. It is attainable, as I will be exposed to more cases each week and will have the opportunity to review the criteria and apply what I’ve learned. As a fundamental skill for PMHNPs, diagnosis is in keeping with the aims of the course.

    3

    Create and Execute 3 Treatment Plans Based on Evidence

    Specific: My goal is to create and carry out a minimum of three treatment plans grounded in evidence for patients suffering from mood or anxiety disorders.

    Measurable: My preceptor will assess each plan and record the evaluations in clinical notes.

    Achievable: With regular oversight and clinical case opportunities, this can be accomplished.

    Relevant: In PMHNP practice, treatment planning is essential.

    Timely: Should be finalized by the end of week 10 of the clinical term.

    American Nurses Credentialing Center, 2023

    This objective focuses on the development and execution of three evidence-based treatment plans for patients suffering from anxiety or mood disorders. I will discuss and evaluate each plan with my preceptor. To make certain that every treatment plan conforms to best-practice standards, I will depend on academic resources and clinical guidelines. I selected this because I want to master treatment planning, which is a crucial skill, before graduation.

    4

    Improve Knowledge of Psychopharmacology

    Specific: My goal is to enhance my knowledge of psychotropic medications, especially SSRIs, stimulants, and antipsychotics.

    Measurable: I will carry out weekly medication reviews and talk about them with my preceptor.

    Achievable: My textbook, online modules, and discussions with my preceptor are among the resources.

    relevant :Core element of psychiatric nursing practice: Medication management.

    Timely: I will monitor learning progress and complete the goal by the end of the clinical term.

    Wheeler, 2020

    With this goal, I aim to enhance my understanding of psychopharmacology. I will examine important categories of medication, including SSRIs, stimulants, and antipsychotics. This will be assessed by means of medication reviews, weekly discussions with my preceptor, and self-reflection. I selected this because managing medication can seem daunting, and I aim to enhance my understanding and self-assurance in this domain.

    5

    Build Rapport with At Least 10 Patients

    Specific: My goal is to establish a successful therapeutic rapport with no fewer than 10 patients.

    Measurable: Patient feedback, preceptor notes, and clinical reflections will indicate the success of rapport-building.

    Achievable: I will apply methods of involvement, empathy, and attentive listening in every interaction with patients.

    Relevant: A strong therapeutic alliance enhances outcomes and is an essential skill for PMHNPs.

    Timely: The goal will be achieved by the end of the 12-week term.

    Wheeler, 2020

    It is vital for therapy to succeed that a good relationship with patients is developed. I aim to connect with at least 10 patients in a meaningful way, utilizing empathy, active listening, and engagement skills. Feedback and clinical documentation will reflect how strong these relationships are. I aim to achieve this goal by the end of the term. This will assist me in establishing trust and honing my therapeutic communication style.

    6

    Master Use of Screening Tools (PHQ-9, GAD-7, Vanderbilt)

    Specific: My goal is to administer and interpret at least three standardized screening tools during clinical sessions with confidence.

    Measurable: My preceptor will assess my comprehension and application of each tool via observation and chart reviews.

    Achievable: I will be able to practice these tools often during my clinical term, as they are commonly used.

    Relevant: In psychiatric evaluations, precise screening is crucial and consistent with the aims of the program.

    Timely: The completion of this goal is scheduled for week 9 of the clinical term.

    American Nurses Credentialing Center, 2023

    For this purpose, I aim to become skilled in using important screening tools such as the PHQ-9, GAD-7, and Vanderbilt forms. During patient intake or follow-up visits, I will practice using them, and my preceptor will assess how I score and interpret results. These tools are crucial for ensuring informed clinical decisions and enhancing patient outcomes.

    7

    Rehearse evaluation of suicide risk and planning for safety

    Specific: I will carry out a comprehensive suicide risk evaluation on no fewer than five patients showing signs of depression or suicidal thoughts.

    Measurable: My preceptor will review and document each assessment.

    Achievable: I will utilize the Columbia-Suicide Severity Rating Scale (C-SSRS) and safety planning templates under supervision.

    Relevant: Preventing suicide is crucial in psychiatric care, and it corresponds with the objectives of the course.

    Timely: The completion of this goal is scheduled for week 10 of the term.

    American Nurses Credentialing Center, 2023

    This aim focuses on building confidence in conducting suicide risk assessments and developing safety plans. I intend to utilize organized tools such as the Columbia-Suicide Severity Rating Scale and safety planning templates. To guarantee that my evaluations are comprehensive and suitable for the risk level of each patient, I will collaborate closely with my preceptor.

    8

    Participate in at Least 2 Family Sessions

    Specific: During my clinical rotation, I aim to observe or co-lead a minimum of two sessions focused on family therapy or psychoeducation.

    Measurable: My preceptor will keep a record of and assess attendance and participation.

    Achievable: There are opportunities for family involvement in outpatient and pediatric settings.

    Relevant: In the field of child and adolescent psychiatry, it is essential to comprehend family dynamics.

    Timely: Should be finished by the end of week 11.

    Wheeler, 2020

    I aim to acquire experience in dealing with families, particularly regarding mental health issues in children and adolescents. I will strive to attend or help lead at least two family sessions, where I will observe communication patterns and the therapist's role. This will aid me in providing better support for family systems and overall patient care.

    9

    Present 1 Case Study During Clinical Rounds

    Specific: I will present a detailed psychiatric case, along with its diagnosis and treatment plan, to my clinical team.

    Measurable: My preceptor or instructor will schedule and evaluate the presentation.

    Achievable: I will select a patient I’ve been monitoring and prepare with my preceptor’s guidance.

    Relevant: Showcasing patient cases enhances critical thinking and equips me for actual teamwork.

    Timely: The completion will occur by the end of week 12.

    Wheeler, 2020

    To achieve this goal, I intend to present a comprehensive case study during rounds. I will choose a patient I have collaborated with and provide a summary of their history, diagnosis, treatment, and response. This exercise will assist in developing my confidence regarding the articulation of clinical reasoning and communication with interdisciplinary teams.

    10

    Enhance the accuracy of documentation and charting

    Specific: I will enhance my clinical documentation by ensuring all chart entries are completed within 24 hours and obtaining weekly feedback from my preceptor.

    Measurable: The accuracy and timeliness will be monitored through the examination of chart audits and preceptor notes.

    Achievable: I will maintain structure by using EMR templates and charting checklists.

    Relevant: Safe and legal psychiatric practice relies heavily on accurate documentation.

    Timely: This will be upheld consistently over the course of the term and reviewed every two weeks.

    American Nurses Credentialing Center, 2023

    This goal pertains to clinical documentation, which is vital for continuity of care, legal precision, and effective communication. To keep organized, I will utilize checklists and EMR templates, and I will make sure to document all encounters within a 24-hour timeframe. My notes will be reviewed weekly by my preceptor for feedback.

    11

    References

    American Nurses Credentialing Center. (2023). Scope and standards of practice for psychiatric-mental health nursing.

    Wheeler, K. (2020). Psychotherapy for the Advanced Practice Psychiatric Nurse: A How-To Guide for Evidence-Based Practice (3rd ed.). Springer Publishing.

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    follow instuuctions attached – ## soapnoteinstructions.docx – ## soapnoteetemplate.docx **## soapnoteinstructions.docx** Comprehensive Psychotherapy Evaluation 1 1. Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic. 2. OAP is an acronym that stands for…

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    follow instuuctions attached

    – ## soapnoteinstructions.docx

    – ## soapnoteetemplate.docx

    **## soapnoteinstructions.docx**

    Comprehensive Psychotherapy Evaluation 1

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

    2. OAP 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 |

    **Make it sure it is psychotherapy on a patient with anxiety/depression**

    **## soapnoteetemplate.docx**

    **Comprehensive Psychiatric Evaluation Template**

    **With Psychotherapy Note**

    Encounter date: ________________________

    Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____

    Reason for Seeking Health Care: ______________________________________________

    **HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

    **SI/HI:** _______________________________________________________________________________

    **Sleep:**_________________________________________
    **Appetite:**\_\_\______________________

    **Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________

    **Current perception of Health**: Excellent Good Fair Poor

    **Psychiatric History:**

    **_Inpatient hospitalizations:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_Outpatient psychiatric treatment:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_Detox/Inpatient substance treatment:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_History of suicide attempts and/or self injurious behaviors:_**\_\_\__________________________________

    **Past Medical History**

    · Major/Chronic Illnesses____________________________________________________

    · Trauma/Injury ___________________________________________________________

    · Hospitalizations __________________________________________________________

    **Past Surgical History**\_\_\_________________________________________________________

    **_Current psychotropic medications:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_Current prescription medications:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_OTC/Nutritionals/Herbal/Complementary therapy:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_Substance use_** _:_(alcohol, marijuana, cocaine, caffeine, cigarettes)

    | | | | |
    | — | — | — | — |
    | **_Substance_** | **_Amount_** | **_Frequency_** | **_Length of Use_** |
    | | | | |
    | | | | |
    | | | | |
    | | | | |

    **Family Psychiatric History:** _____________________________________________________

    **Social History**

    **Lives**: Single family House/Condo/ with stairs: ___________
    **Marital Status**:________

    **Education**:____________________________

    **Employment Status**: ______
    **Current/Previous occupation type**: _________________

    **Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________

    **Sexual Orientation:** _______ Sexual Activity: ____
    **Contraception Use**: ____________

    **Family Composition:** Family/Mother/Father/Alone
    **: _____________________________**

    **Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________**

    **\_\_\______________________________________________________________________**

    **Health Maintenance**

    **Screening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, Dementia**

    **Exposures:**

    **Immunization HX:**

    **Review of Systems (at least 3 areas per system):**

    General:

    HEENT:

    Neck:

    Lungs:

    Cardiovascular:

    Breast:

    GI:

    Male/female genital:

    GU:

    Neuro:

    Musculoskeletal:

    Activity & Exercise:

    Psychosocial:

    Derm:

    Nutrition:

    Sleep/Rest:

    LMP:

    STI Hx:

    **Physical Exam**

    BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
    **percentile**) _____

    General:

    HEENT:

    Neck:

    Pulmonary:

    Cardiovascular:

    Breast:

    GI:

    Male/female genital:

    GU:

    Neuro:

    Musculoskeletal:

    Derm:

    Psychosocial:

    Misc.

    **Mental Status Exam**

    Appearance:

    Behavior:

    Speech:

    Mood:

    Affect:

    Thought Content:

    Thought Process:

    Cognition/Intelligence:

    Clinical Insight:

    Clinical Judgment:

    | |
    | — |
    | **Psychotherapy Note** |
    | **Therapeutic Technique Used:** |
    | **Session Focus and Theme:** |
    | **Intervention Strategies Implemented:** |
    | **Evidence of Patient Response**: |

    **Plan:**

    **Differential Diagnoses**

    **1.**

    **2.**

    **Principal Diagnoses**

    **1.**

    **2.**

    **Plan:**

    **Diagnosis #1**

    **Diagnostic Testing/Screening:**

    **Pharmacological Treatment:**

    **Non-Pharmacological Treatment:**

    **Patient/Family Education:**

    **Referrals:**

    **Follow-up:**

    **Anticipatory Guidance:**

    **Diagnosis #2**

    **Diagnostic Testing/Screening Tool:**

    **Pharmacological Treatment:**

    **Non-Pharmacological Treatment:**

    **Patient/Family Education:**

    **Referrals:**

    **Follow-up:**

    **Anticipatory Guidance:**

    **Signature (with appropriate credentials): __________________________________________**

    **Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________**

    **DEA#: 101010101 STU Clinic LIC# 10000000**

    **Tel: (000) 555-1234 FAX: (000) 555-12222**

    Patient Name: (Initials)______________________________ Age ___________

    Date: _______________

    **RX ______________________________________**

    **SIG:**

    **Dispense**: ___________
    **Refill:** _________________

    **No Substitution**

    **Signature:** ____________________________________________________________

    **Rev. 2272022 LM**

    **## soapnoteetemplate.docx**

    **Comprehensive Psychiatric Evaluation Template**

    **With Psychotherapy Note**

    Encounter date: ________________________

    Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____

    Reason for Seeking Health Care: ______________________________________________

    **HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

    **SI/HI:** _______________________________________________________________________________

    **Sleep:**_________________________________________
    **Appetite:**\_\_\______________________

    **Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________

    **Current perception of Health**: Excellent Good Fair Poor

    **Psychiatric History:**

    **_Inpatient hospitalizations:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_Outpatient psychiatric treatment:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_Detox/Inpatient substance treatment:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_History of suicide attempts and/or self injurious behaviors:_**\_\_\__________________________________

    **Past Medical History**

    · Major/Chronic Illnesses____________________________________________________

    · Trauma/Injury ___________________________________________________________

    · Hospitalizations __________________________________________________________

    **Past Surgical History**\_\_\_________________________________________________________

    **_Current psychotropic medications:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_Current prescription medications:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_OTC/Nutritionals/Herbal/Complementary therapy:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_Substance use_** _:_(alcohol, marijuana, cocaine, caffeine, cigarettes)

    | | | | |
    | — | — | — | — |
    | **_Substance_** | **_Amount_** | **_Frequency_** | **_Length of Use_** |
    | | | | |
    | | | | |
    | | | | |
    | | | | |

    **Family Psychiatric History:** _____________________________________________________

    **Social History**

    **Lives**: Single family House/Condo/ with stairs: ___________
    **Marital Status**:________

    **Education**:____________________________

    **Employment Status**: ______
    **Current/Previous occupation type**: _________________

    **Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________

    **Sexual Orientation:** _______ Sexual Activity: ____
    **Contraception Use**: ____________

    **Family Composition:** Family/Mother/Father/Alone
    **: _____________________________**

    **Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________**

    **\_\_\______________________________________________________________________**

    **Health Maintenance**

    **Screening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, Dementia**

    **Exposures:**

    **Immunization HX:**

    **Review of Systems (at least 3 areas per system):**

    General:

    HEENT:

    Neck:

    Lungs:

    Cardiovascular:

    Breast:

    GI:

    Male/female genital:

    GU:

    Neuro:

    Musculoskeletal:

    Activity & Exercise:

    Psychosocial:

    Derm:

    Nutrition:

    Sleep/Rest:

    LMP:

    STI Hx:

    **Physical Exam**

    BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
    **percentile**) _____

    General:

    HEENT:

    Neck:

    Pulmonary:

    Cardiovascular:

    Breast:

    GI:

    Male/female genital:

    GU:

    Neuro:

    Musculoskeletal:

    Derm:

    Psychosocial:

    Misc.

    **Mental Status Exam**

    Appearance:

    Behavior:

    Speech:

    Mood:

    Affect:

    Thought Content:

    Thought Process:

    Cognition/Intelligence:

    Clinical Insight:

    Clinical Judgment:

    | |
    | — |
    | **Psychotherapy Note** |
    | **Therapeutic Technique Used:** |
    | **Session Focus and Theme:** |
    | **Intervention Strategies Implemented:** |
    | **Evidence of Patient Response**: |

    **Plan:**

    **Differential Diagnoses**

    **1.**

    **2.**

    **Principal Diagnoses**

    **1.**

    **2.**

    **Plan:**

    **Diagnosis #1**

    **Diagnostic Testing/Screening:**

    **Pharmacological Treatment:**

    **Non-Pharmacological Treatment:**

    **Patient/Family Education:**

    **Referrals:**

    **Follow-up:**

    **Anticipatory Guidance:**

    **Diagnosis #2**

    **Diagnostic Testing/Screening Tool:**

    **Pharmacological Treatment:**

    **Non-Pharmacological Treatment:**

    **Patient/Family Education:**

    **Referrals:**

    **Follow-up:**

    **Anticipatory Guidance:**

    **Signature (with appropriate credentials): __________________________________________**

    **Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________**

    **DEA#: 101010101 STU Clinic LIC# 10000000**

    **Tel: (000) 555-1234 FAX: (000) 555-12222**

    Patient Name: (Initials)______________________________ Age ___________

    Date: _______________

    **RX ______________________________________**

    **SIG:**

    **Dispense**: ___________
    **Refill:** _________________

    **No Substitution**

    **Signature:** ____________________________________________________________

    **Rev. 2272022 LM**

    **## soapnoteinstructions.docx**

    Comprehensive Psychotherapy Evaluation 1

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

    2. OAP 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 |

    **Make it sure it is psychotherapy on a patient with anxiety/depression**

    **## soapnoteetemplate.docx**

    **Comprehensive Psychiatric Evaluation Template**

    **With Psychotherapy Note**

    Encounter date: ________________________

    Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____

    Reason for Seeking Health Care: ______________________________________________

    **HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

    **SI/HI:** _______________________________________________________________________________

    **Sleep:**_________________________________________
    **Appetite:**\_\_\______________________

    **Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________

    **Current perception of Health**: Excellent Good Fair Poor

    **Psychiatric History:**

    **_Inpatient hospitalizations:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_Outpatient psychiatric treatment:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_Detox/Inpatient substance treatment:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_History of suicide attempts and/or self injurious behaviors:_**\_\_\__________________________________

    **Past Medical History**

    · Major/Chronic Illnesses____________________________________________________

    · Trauma/Injury ___________________________________________________________

    · Hospitalizations __________________________________________________________

    **Past Surgical History**\_\_\_________________________________________________________

    **_Current psychotropic medications:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_Current prescription medications:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_OTC/Nutritionals/Herbal/Complementary therapy:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_Substance use_** _:_(alcohol, marijuana, cocaine, caffeine, cigarettes)

    | | | | |
    | — | — | — | — |
    | **_Substance_** | **_Amount_** | **_Frequency_** | **_Length of Use_** |
    | | | | |
    | | | | |
    | | | | |
    | | | | |

    **Family Psychiatric History:** _____________________________________________________

    **Social History**

    **Lives**: Single family House/Condo/ with stairs: ___________
    **Marital Status**:________

    **Education**:____________________________

    **Employment Status**: ______
    **Current/Previous occupation type**: _________________

    **Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________

    **Sexual Orientation:** _______ Sexual Activity: ____
    **Contraception Use**: ____________

    **Family Composition:** Family/Mother/Father/Alone
    **: _____________________________**

    **Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________**

    **\_\_\______________________________________________________________________**

    **Health Maintenance**

    **Screening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, Dementia**

    **Exposures:**

    **Immunization HX:**

    **Review of Systems (at least 3 areas per system):**

    General:

    HEENT:

    Neck:

    Lungs:

    Cardiovascular:

    Breast:

    GI:

    Male/female genital:

    GU:

    Neuro:

    Musculoskeletal:

    Activity & Exercise:

    Psychosocial:

    Derm:

    Nutrition:

    Sleep/Rest:

    LMP:

    STI Hx:

    **Physical Exam**

    BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
    **percentile**) _____

    General:

    HEENT:

    Neck:

    Pulmonary:

    Cardiovascular:

    Breast:

    GI:

    Male/female genital:

    GU:

    Neuro:

    Musculoskeletal:

    Derm:

    Psychosocial:

    Misc.

    **Mental Status Exam**

    Appearance:

    Behavior:

    Speech:

    Mood:

    Affect:

    Thought Content:

    Thought Process:

    Cognition/Intelligence:

    Clinical Insight:

    Clinical Judgment:

    | |
    | — |
    | **Psychotherapy Note** |
    | **Therapeutic Technique Used:** |
    | **Session Focus and Theme:** |
    | **Intervention Strategies Implemented:** |
    | **Evidence of Patient Response**: |

    **Plan:**

    **Differential Diagnoses**

    **1.**

    **2.**

    **Principal Diagnoses**

    **1.**

    **2.**

    **Plan:**

    **Diagnosis #1**

    **Diagnostic Testing/Screening:**

    **Pharmacological Treatment:**

    **Non-Pharmacological Treatment:**

    **Patient/Family Education:**

    **Referrals:**

    **Follow-up:**

    **Anticipatory Guidance:**

    **Diagnosis #2**

    **Diagnostic Testing/Screening Tool:**

    **Pharmacological Treatment:**

    **Non-Pharmacological Treatment:**

    **Patient/Family Education:**

    **Referrals:**

    **Follow-up:**

    **Anticipatory Guidance:**

    **Signature (with appropriate credentials): __________________________________________**

    **Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________**

    **DEA#: 101010101 STU Clinic LIC# 10000000**

    **Tel: (000) 555-1234 FAX: (000) 555-12222**

    Patient Name: (Initials)______________________________ Age ___________

    Date: _______________

    **RX ______________________________________**

    **SIG:**

    **Dispense**: ___________
    **Refill:** _________________

    **No Substitution**

    **Signature:** ____________________________________________________________

    **Rev. 2272022 LM**

    **## soapnoteinstructions.docx**

    Comprehensive Psychotherapy Evaluation 1

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

    2. OAP 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 |

    **Make it sure it is psychotherapy on a patient with anxiety/depression**

    **## soapnoteetemplate.docx**

    **Comprehensive Psychiatric Evaluation Template**

    **With Psychotherapy Note**

    Encounter date: ________________________

    Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____

    Reason for Seeking Health Care: ______________________________________________

    **HPI**:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

    **SI/HI:** _______________________________________________________________________________

    **Sleep:**_________________________________________
    **Appetite:**\_\_\______________________

    **Allergies**(Drug/Food/Latex/Environmental/Herbal): ___________________________________

    **Current perception of Health**: Excellent Good Fair Poor

    **Psychiatric History:**

    **_Inpatient hospitalizations:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_Outpatient psychiatric treatment:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_Detox/Inpatient substance treatment:_**

    | | | | |
    | — | — | — | — |
    | **_Date_** | **_Hospital_** | **_Diagnoses_** | **_Length of Stay_** |
    | | | | |
    | | | | |

    **_History of suicide attempts and/or self injurious behaviors:_**\_\_\__________________________________

    **Past Medical History**

    · Major/Chronic Illnesses____________________________________________________

    · Trauma/Injury ___________________________________________________________

    · Hospitalizations __________________________________________________________

    **Past Surgical History**\_\_\_________________________________________________________

    **_Current psychotropic medications:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_Current prescription medications:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_OTC/Nutritionals/Herbal/Complementary therapy:_**

    \_\_\_______________________________________ ________________________________

    \_\_\_______________________________________ ________________________________

    **_Substance use_** _:_(alcohol, marijuana, cocaine, caffeine, cigarettes)

    | | | | |
    | — | — | — | — |
    | **_Substance_** | **_Amount_** | **_Frequency_** | **_Length of Use_** |
    | | | | |
    | | | | |
    | | | | |
    | | | | |

    **Family Psychiatric History:** _____________________________________________________

    **Social History**

    **Lives**: Single family House/Condo/ with stairs: ___________
    **Marital Status**:________

    **Education**:____________________________

    **Employment Status**: ______
    **Current/Previous occupation type**: _________________

    **Exposure to:** ___Smoke____ ETOH ____Recreational Drug Use: __________________

    **Sexual Orientation:** _______ Sexual Activity: ____
    **Contraception Use**: ____________

    **Family Composition:** Family/Mother/Father/Alone
    **: _____________________________**

    **Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________**

    **\_\_\______________________________________________________________________**

    **Health Maintenance**

    **Screening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, Dementia**

    **Exposures:**

    **Immunization HX:**

    **Review of Systems (at least 3 areas per system):**

    General:

    HEENT:

    Neck:

    Lungs:

    Cardiovascular:

    Breast:

    GI:

    Male/female genital:

    GU:

    Neuro:

    Musculoskeletal:

    Activity & Exercise:

    Psychosocial:

    Derm:

    Nutrition:

    Sleep/Rest:

    LMP:

    STI Hx:

    **Physical Exam**

    BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
    **percentile**) _____

    General:

    HEENT:

    Neck:

    Pulmonary:

    Cardiovascular:

    Breast:

    GI:

    Male/female genital:

    GU:

    Neuro:

    Musculoskeletal:

    Derm:

    Psychosocial:

    Misc.

    **Mental Status Exam**

    Appearance:

    Behavior:

    Speech:

    Mood:

    Affect:

    Thought Content:

    Thought Process:

    Cognition/Intelligence:

    Clinical Insight:

    Clinical Judgment:

    | |
    | — |
    | **Psychotherapy Note** |
    | **Therapeutic Technique Used:** |
    | **Session Focus and Theme:** |
    | **Intervention Strategies Implemented:** |
    | **Evidence of Patient Response**: |

    **Plan:**

    **Differential Diagnoses**

    **1.**

    **2.**

    **Principal Diagnoses**

    **1.**

    **2.**

    **Plan:**

    **Diagnosis #1**

    **Diagnostic Testing/Screening:**

    **Pharmacological Treatment:**

    **Non-Pharmacological Treatment:**

    **Patient/Family Education:**

    **Referrals:**

    **Follow-up:**

    **Anticipatory Guidance:**

    **Diagnosis #2**

    **Diagnostic Testing/Screening Tool:**

    **Pharmacological Treatment:**

    **Non-Pharmacological Treatment:**

    **Patient/Family Education:**

    **Referrals:**

    **Follow-up:**

    **Anticipatory Guidance:**

    **Signature (with appropriate credentials): __________________________________________**

    **Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________**

    **DEA#: 101010101 STU Clinic LIC# 10000000**

    **Tel: (000) 555-1234 FAX: (000) 555-12222**

    Patient Name: (Initials)______________________________ Age ___________

    Date: _______________

    **RX ______________________________________**

    **SIG:**

    **Dispense**: ___________
    **Refill:** _________________

    **No Substitution**

    **Signature:** ____________________________________________________________

    **Rev. 2272022 LM**

    – 1
    – 2

  • [Solved] article

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    Executive Solution Overview

    Being curious about your practice leads to questioning and having an attitude of inquiry. **Answer the following statements and submit the PICO Question Worksheet via Black Board using Word**. 1. Briefly describe a clinical issue. Support the issue with references. State why it is important. Clearly…

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    Assignment Prompt & Instructions

    Being curious about your practice leads to questioning and having an attitude of inquiry.
    **Answer the following statements and submit the PICO Question Worksheet via Black Board using Word**.
    1. Briefly describe a clinical issue. Support the issue with references. State why it is important. Clearly describe the problem or issue.   Do not include a solution to the issue.
          2. Describe the current practice (if known)
         3. Identify the PICO Components
    1. P (patient, population, or problem)
    2. I (Intervention, nursing treatment or action or indicator)
    3. C (Comparison usually to current practice or another intervention, or taking no action)
    4. O (Outcome specific effects from the intervention, or what matters to the nurse or patient)
    5. T (Time, If applicable such as before surgery or within 2 day)
    4. Complete the PICO question in the proper PICO format. Use the PICO Template as a guide
    5. Identify the type of PICO question and the type of studies to answer the PICO question.
    6. PICO Breakdown- create synonyms/keyword table for key search terms
    \
    PICODevelopmentWorksheet420.docx](https://www.sweetstudy.com/files/picodevelopmentworksheet420-docx "PICODevelopmentWorksheet420.docx")
    \
    PICOTemplate1.docx](https://www.sweetstudy.com/files/picotemplate1-docx "PICOTemplate1.docx")
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    TypeofClinicalQuestionTypeStudyDesignTable.pdf](https://www.sweetstudy.com/files/typeofclinicalquestiontypestudydesigntable-pdf "TypeofClinicalQuestionTypeStudyDesignTable.pdf")

  • [Solved] assign 6 health policy

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    Assignment Prompt & Instructions

    \
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  • [Solved] Weekly Clinical Experience 6 Geriatrics

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    Describe your clinical experience for this week for a geriatric patient 65 years or older – Did you face any challenges, any success? If so, what were they? – Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differential …

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    Assignment Prompt & Instructions

    Describe your clinical experience for this week for a geriatric patient 65 years or older
    – Did you face any challenges, any success? If so, what were they?
    – Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differential diagnosis with rationales.
    – Mention the health promotion intervention for this patient.
    – What did you learn from this week's clinical experience that can beneficial for you as an advanced practice nurse?
    – Support your plan of care with the current peer-reviewed research guideline.
    **Submission Instructions:**
    – Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources within 5 years 2020-2025