Each student will create a focused SOAP note PowerPoint presentation. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive psychiatric SOAP note is to be written using the attached template below. 

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 Guidelines  (Links to an external site.)or APA Clinical Guidelines (Links to an external site.), research articles, and the role of the PMHNP in your presentation.   

Psychiatric Assessment of Infants and Toddlers (Links to an external site.) 

Psychiatric Assessment of Children and Adolescents (Links to an external site.) 

Reminder: It is important that you complete this assessment using your critical thinking skills.  You are expected to synthesis your clinical assessment, formulate a psychiatric diagnosis, and develop a treatment plan independently.   It is not acceptable to document “my preceptor made this diagnosis.”  An example of the appropriate descriptors of the clinical evaluation is listed below.  It is not acceptable to document “within normal limits.”   

Graduate Mental Status Exam Guide.docx