PMHNP Comprehensive Psychiatric SOAP Note New Final

Comprehensive Psychiatric SOAP NoteDate: [date name="Date" default="07/16/2022"]
Patient Name: [text name="PatientName" default=""]
Patient Date of Birth: [text name="DOB" default=""]
Medical Record Number: [text name="Medicalrecord" default=""]
Provider Name: [text name="ProviderName" default=""]~SUBJECTIVE~I. Reason for the evaluationA. Chief Complaint:
[textarea name="ChiefComplaint" memo="What the patient states he or she wants help with - Verbatim statement in Quotes"]
B. Indentifying data
1. Age: [text name="Age" default=""]
2. Sex / Gender preference: [select name="sexgender" value="|Male|Female|Trans|Other"]
3. Race / Ethnicity:[select name="race" value=" |Caucasation|Hispanic|American Indian|Alaska Native|Black or African American|Native Hawaiian|Pacific Islander|Asian|Two or More Races|Other|No Response"]
4. Relationship Status:[select name="relationship" value="|Single|Married|Widowed|Partnered|Seperated|Divorced|Other|No Response"]
5. Sexual Orientation:[text name="Orientation" default=""]
6. Children:[text name="Children" default=""]
7. How Arrived?:[text name="Arrival" default=""]
8. Who referred? Why?:[text name="Referral" default=""]
9. Mental Health providers?:[text name="Psychiatrist" default=""]
10. Number of times seen in this setting:[text name="Repeat" default=""]
C. Source and reliability of data: [text name="Realiability" default=""]II. History of present IllnessA. Onset, duration, or change in symptoms over time:
[textarea name="ChiefComplaint" memo="Organized chronologically - Patient's perception of changes in himself or herself over time - Others' perception of changes in the patient (e.g., spouse, employer, and friends)"]
B. Stressors and precipitating factors:
[textarea name="CurrentIllness" memo="Why now?"]
C. Baseline functioning:
[textarea name="Baseline" default=""]D. Last period of stability:
[textarea name="Stability" default=""]E. Scales and screening:
[textarea name="Screening" default=""]III, Past psychiatric historyA. Trauma history:
[textarea name="TraumaHistory" memo="Ten most significant disturbing events in life"]B. Inpatient hospitalization:
[textarea name="InpatientHospitalizations" memo="1. Location, dates, and lengths of stay 2. Diagnoses 3. Previous episodes of current symptoms 4. Previous episodes of other disorders not described in history of current illness 5. Legal status 6. Use of medications or other treatments, including doses, blood levels, clinical response 7. Perception of helpfulness"]C. Outpatient Treatments:
[textarea name="OutpatientTreatments" memo="1. Dates, duration, and frequency of sessions 2. Location, type, and focus of treatment or therapy 3. Perception of helpfulness"]IV. History of substance use and abuseA. Episodes of alcohol abuse:
[textarea name="AlcoholUse" memo="1. What, how much, and consequences (e.g., charges for driving under the influence[DUI), other legal sequelae,and loss of relationships,jobs, and opportunities) 2. Does the patient or others think he or she has a problem? 3. Typical pattern of use 4. History of blackouts, seizures, complicated withdrawal, or delirium tremens 5. History of suicide ideation, gestures, or attempts while intoxicated or withdrawing 6. Longest period of sobriety 7. What facilitates sobriety? 8. Previous treatments (e.g., detoxification, rehabilitation, counseling, and Alcoholics Anonymous)"]B. Episodes of illicit or prescription drug abuse:
[textarea name="DrugUse" memo="1. What, amount, route of administration, and consequences (e.g., DUIs, other legal sequelae, and loss of relationships, jobs, and opportunities) 2. Does the patient or others think he or she has a problem? 3. Typical pattern of use 4. History of suicide ideation, gestures, or attempts while intoxicated or withdrawing 5. Longest period of sobriety 6. What facilitates sobriety? 7. Previous treatments (e.g., detoxification, rehabilitation, counseling, and Narcotics Anonymous)"]C. Tobacco Use:
[textarea name="Tobacco" memo="1. Number of cigarettes or packs per day 2. Years patient has smoked 3. Cessation attempts"]D. Caffeine Use:
[textarea name="Caffeine" memo="1. Form (coffee, cola, tea, and pills) 2. Amount consumed per day 3. Cessation attempts"]E. Over-the-counter drugs or "herbal" medications:
[textarea name="Herbals" memo="1. What, how much, purpose, frequency, side effects, and ingteractions with prescribed medication 2. Perceptions of helpfulness or efficacy"]V. Medical HistoryA. Past and current medical problems:
[textarea name="MedicalHistory" memo="1. Illnesses, operations, and hospitalizations, especially history of open or closed head injury, birth trauma, seizure disorder, and encephalitis, meningitis, thyroid dysfunction, Cardiac"]B. Past and current medications:
[textarea name="Medications" memo="1. Dosages, blood levels, and clinical response 2. Adherence"]C. Primary care physician, specialists, and phone numbers:
[textarea name="Physicians" default=""]D. Allergies (and reactions):
[textarea name="Allergies" default=""]E. LMP: [text name="LMP" default=""]VI. Family historyA. Psychiatric or substance use disorders:
[textarea name="FamilyHistoryPsych" memo="1. Have any family members undergone psychiatric or substance abuse treatment (inpatient or outpatient), attempted or completed a suicide, had problems with drugs or alcohol, and behaved strangely? 2. Have any family members successfully used any psychotropic medications for the same or similar symptoms? 3. Family attitudes toward mental illness"]B. Pertinent medical disorders in blood relatives (e.g., seizure disorder or thyroid disease):
[textarea name="FamilyMedicalHistory"]VII. Developmental historyA. Developmental milestones and family of origin:
[textarea name="DevelopmentalMilestones" memo="1. Information about mother's pregnancy and delivery 2. Were developmental milestones reached as expected? 3. Childhood temperament and important family events (e.g., death, separation, and divorce) 4. Information about early experiences and relationships (e.g., school experiences, academic performance, delinquency, family of origin relationships, family stability, early sexual experiences, and history of abuse or neglect)"]
B. Important cultural or religious influences:
[textarea name="Religious" memo="Values, beliefs, or framework for meaning"]C. Educational history:
[textarea name="Education" default=""]
D. Occupational and military history:
[textarea name="Occupation" memo="1. Number and types of jobs; reasons for termination 2. Highest rank attained; conditions of discharge 3. History of disciplinary problems or combat"]E. Relavent Legal history:
[textarea name="LegalHistory" default=""]VIII. Current Social SituationA. Living arrangements:
[textarea name="LivingArrangement" memo="(e.g., where, with whom, for how long, how stable, and how satisfactory or desirable)"]B. Employment:
[textarea name="Employment" memo="(e.g., where, for how long, how stable, and how satisfactory or desirable)"]C. Financial:
[textarea name="Financial" memo="(e.g., current source of income, how stable, and how adequate)"]D. Insurance coverage:
[textarea name="Insurance"]E. Support system(s):
[textarea name="Support"]F. Past and present levels of functioning
[textarea name="Functioning" memo="1. Marriage, parenting, and work 2. Patient strengths and strategies used to manage stress, resources, or positive memories (draw a line and place important positive memories and events) 3. Current functional deficits (e.g., activities of daily living, task performance, and relationships)"]IX. Violence historyA. To self
[textarea name="SelfViolence" memo="1. What, when, where, how, why; warning signs or symptoms, triggers, and consequences 2. How intense, specific, and controllable is current ideation"]
B. To others or property
[textarea name="OtherViolence" memo="1. What, when, where, how, why; warning signs or symptoms, triggers, and consequences 2. How intense, specific, and controllable is current ideation"]C. Current access to weapons
[textarea name="Weapons" memo="1. What, where, why; plan for use; plan for disposition of weapon 2. How will disposition of weapons be verified?"]X. Psychiatric review of systems (ROS):
[textarea name="PsychROS" memo="A. Includes all symptoms not just those part of the current episode or presentation B. May have to ask specific questions about the presence or absence of these symptoms"]
"Are you now or have you ever had any of the following...A. Anxiety symptoms
[textarea name="Anxiety" memo="Shortness of breath, heart palpitations, panic attacks, sweating, flushing, hyperventilation, sense of doom, fear of death or collapse, cold or clammy skin, and tingling sensations in the extremities."]B. Mood symptoms
[textarea name="MoodSymptoms" memo="Sadness, irritability, anergia,fatigue, lethargy, tearfulness,increased or decreased appetite or energy, changes in sleep or libido, suicide ideation, homocide ideation, hypomania (e.g., spending sprees, increased energy, and religious preoccupation beyond baseline), and feelings of hopelessness, helplessness, or worthlessnes"]C. Psychotic or cognitive symptoms
[textarea name="Psychotic" memo="Hallucinations, delusions,thought insertion, thoughtnblocking, thought broadcasting, flight of ideas, hyperreligiosity, tangentially, looseness of associations, and circumstantiality"]
~OBJECTIVE~
*Vital Signs
Height: [text name="Height" default=""]
Weight: [text name="Weight" default=""]
BMI: [text name="BMI" default=""]
Temp (C): [text name="Temp" default=""]
Pulse: [text name="Pulse" default=""]
B/P: [text name="BP" default=""]
Resp: [text name="Res" default=""]
SPO2: [text name="SPO2" default=""]
Pain: [text name="Pain" default=""]
*Labs
[textarea name="Labs" default=""]
*Test Results
[textarea name="TestResults" default=""]XI. Physical Exam
General:[text name="General" memo="Awake, alert, oriented, well groomed"]
HEENT: [text name="HEENT" memo="PERRLA, Normocephalic, Hair short brown, no visible or palpable abnormalities, normal dentition, oropharynx clear, mucous membranes pink, hearing intact."]
Neck: [text name="Neck" memo="Supple, no thyromegaly, no JVD, no cervical mass of lymphadenopathy"]
CV: [text name="CV" memo="RRR, (-) for murmurs, gallop, or peripheral bruits, peripheral pulses 3+"]
Hematologic: [text name="Hematologic" memo="(-) Bruising or petechia"]
Chest: [text name="Chest" memo="CTA, normal effort, no adventitious sounds"]
Abdomen: [text name="Abdomen" memo="Soft, BS +, ND, NT, no hepatoslenomegaly or palpable mass. Negative for abdominal or thoracic bruits"]
GI/GU: [text name="GIGU" memo="Continent, Flat Abdomen, denies stomach pain, heart burn, bloating, or nausea"]
Extremities/Skin: [text name="Skin" memo="Warm, dry, intact, no edema, no lesions, acne, rash, excoriations, or jaundice, capillary refill <2 seconds"]
Musculoskeletal: [text name="Musculoskeletal" memo="Ambulatory, normal gait, DTR’s intact, normal strength, Full ROM"]
Cranial nerves: [text name="CranialNerves" memo="II – XII intact"]XII. Mental status examination (MSE)[comment memo="Informal: begins immediately on contact with the patient and includes an informal assessment of the patient's characteristics\n 1. Appearance\n 2. Manner of relating\n 3. Use of language\n 4. Mood and affect\n 5. Content of Speech\n 6. Perceptions\n 7. Abstracting ability\n 8. Judgment\n 9. Insight"][comment memo="Formal: focused, structured assessment of the patient's characteristics"]
1. Appearance: [text name="Appearance" memo="overall appearance, dress, grooming"]
2. Attitude: [text name="Attitude" memo="attitude toward examiner (e.g., hostile, cooperative, evasive)"]
3. Behavior and psychomotor activity: [text name="Behavior" memo="gait, carriage, posture, activity level"]
4. Speech: [text name="Speech" memo="Rate, amount, tone,impairment, aphasia"]
5. Mood and affect: [text name="Mood" memo="a. Mood (i.e., how the patient reports feeling) in relation to affect (i.e., emotional expression observed by the therapist) b. Depth and range of emotional expression"]
6. Perception:
a. Hallucinations: [text name="Hallucinations" memo="i. Auditory ii. Visual iii. Gustatory: taste (temporal lobe dysfunction?) iv. Olfactory: smell (temporal lobe dysfunction?) v. Tactile: Skin sensations (alcohol withdrawal and intoxication?) vi. Kinesthetic: feeling movement when none occurs vii. Hypnagogic: occurs while falling asleep viii. Hypnopompic: occurs while waking up"]
b. Illusions: [text name="Illusions" memo="misinterpretations of actual sensory stimuli"]
c. Depersonalization: [text name="Depersonalization" memo="feels detached and views self as unreal"]
d. Derealization: [text name="Derealization" memo="experiences objects and persons outside of self as unreal"]
7. Thought process: [text name="ThoughtProcess" memo="The pattern of a patient's speech allows the therapist to observe the quality of the thought process, including its flow, logic, and assocations. Abnormalities include the following: i. Loose associations (LOAs) ii. Tangentiality iii. Circumstantiality iv. Thought blocking (TB) v. Thought insertion (T) vi. Flight of ideas (FOAs) vii. Perseveration viii. Echolalia"]
8. Content of thought:
a. Delusions: [text name="Delusions" memo=" i. Paranoid or persecutory ii. Grandiose iii. Nihilistic iv. Somatic v. Bizarre"]
b. Ideas of reference: [text name="Reference"]
c. Obsessions: [text name="Obsessions"]
d. Suicidal thoughts: [text name="SuicidalThoughts"]
e. Homicidal thoughts: [text name="HomicidalThoughts"]
9. Judgment: [text name="Judgement" memo="a. An assessment of social judgement involves determining whether a patient understands the consequences of his or her actions b. Must recognize differences in cultural values when assessing judgment c. \"What would you do if you found a sealed, stamped, addressed envelope on the sidewalk?\""]
10. Insight: [text name="Insight" memo="a. Must assess whether a person is aware of a problem, the cause of the problem, and what type of help is needed to address the problem"]
11. Cognition: [comment memo="A formal MSE measures the ability of the brain to function by assessing the following cognitive functions:"]
i. Consciousness: [text name="Consciousness" memo="AOx4, alert, confused, drowsy, somnolent, obtunded, delirious, stuporous, and comatose"]
ii. Orientation: [text name="Orientation" memo="knows who he or she is, where he or she is, and what day it is"]
iii. Memory: [text name="Memory" memo="can remember what was eaten for breakfast today; has remote memory for long-past events"]
iv. Recall: [text name="Recall" memo="can recall three objects after 5 minutes"]
v. Registration: [text name="Registration" memo="can name three objects immediately"]
vi. Attention: [text name="Attention" memo="can spell world forward and backward"]
vii. Calculation: [text name="Calculation" memo="can do serial 7's or count backward from 20"]
viii. Language: [text name="Language" memo="can name items, repeat a phrase, follow simple commands, read, write, and copy a design"]~ASSESSMENT~
XIII. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) differential diagnosis
A. On a single axis, lists the principal psychiatric, neurodevelopmental, neurocognitive, and other disorders requiring further assessment[textarea name="Diagnosis" memo="1. Include treatment options
2. Patient input regarding options
3. Obstacles to treatment
4. ICD-10 codes before the disorder name" default="Primary Diagnosis"]
B. Includes so-called "rule-out' and/or "provisional" diagnoses[textarea name="Differential" memo="ICD-10 codes are listed before each disorder name" default="Differential Diagnosis"]XVI.Case formulation[comment memo="A. Presents a brief summary of the patient and rationalizes the diagnoses\n 1. Minimal identifying data, including past diagnosis\n 2. Abbreviated recapitulation of presenting symptoms, onset, and course\n 3. Draws from all sections of the database as needed\n\nB. Outlines the contributing factors, precipitants, and stressors\n\nC. Summarizes the logic behind the differential diagnoses"]~PLAN~
XIV. Treatment plan (Devise plan from assessment data and include rationales with references for decisions)
A. Biological
1. Medications (e.g., name, dose, route, for what purpose, and patient's level of understanding of medication education)
2. Diagnostic tests (e.g., where, when, and who will administer)
3. Referrals for primary care
B. Psychological
1. Therapeutic modalities to be used and with what focus
a. Individual psychotherapy?
b. Group psychotherapy?
c. Family therapy?
d. Case management?
e. Holistic options?
f. Complimentary therapies?
C. Social
1. Support or self-help groups
2. Mobilization of family resources
3. Vocational rehabilitation
4. Financial planning
D. Strengths
1. Overt identification of patient strengths, values, and beliefs to support or draw from in implementing the identified treatment planI have read and agree to the above information - [text name="ProviderName2"]Reference - Wheeler, K. (2022). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice. Springer Publishing Company.
Comprehensive Psychiatric SOAP NoteDate:
Patient Name:
Patient Date of Birth:
Medical Record Number:
Provider Name: ~SUBJECTIVE~I. Reason for the evaluationA. Chief Complaint:
What the patient states he or she wants help with - Verbatim statement in Quotes
B. Indentifying data
1. Age:
2. Sex / Gender preference:
3. Race / Ethnicity:
4. Relationship Status:
5. Sexual Orientation:
6. Children:
7. How Arrived?:
8. Who referred? Why?:
9. Mental Health providers?:
10. Number of times seen in this setting:
C. Source and reliability of data: II. History of present IllnessA. Onset, duration, or change in symptoms over time:
Organized chronologically - Patient's perception of changes in himself or herself over time - Others' perception of changes in the patient (e.g., spouse, employer, and friends)
B. Stressors and precipitating factors:
Why now?
C. Baseline functioning:
D. Last period of stability:
E. Scales and screening:
III, Past psychiatric historyA. Trauma history:
Ten most significant disturbing events in lifeB. Inpatient hospitalization:
1. Location, dates, and lengths of stay 2. Diagnoses 3. Previous episodes of current symptoms 4. Previous episodes of other disorders not described in history of current illness 5. Legal status 6. Use of medications or other treatments, including doses, blood levels, clinical response 7. Perception of helpfulnessC. Outpatient Treatments:
1. Dates, duration, and frequency of sessions 2. Location, type, and focus of treatment or therapy 3. Perception of helpfulnessIV. History of substance use and abuseA. Episodes of alcohol abuse:
1. What, how much, and consequences (e.g., charges for driving under the influence[DUI), other legal sequelae,and loss of relationships,jobs, and opportunities) 2. Does the patient or others think he or she has a problem? 3. Typical pattern of use 4. History of blackouts, seizures, complicated withdrawal, or delirium tremens 5. History of suicide ideation, gestures, or attempts while intoxicated or withdrawing 6. Longest period of sobriety 7. What facilitates sobriety? 8. Previous treatments (e.g., detoxification, rehabilitation, counseling, and Alcoholics Anonymous)B. Episodes of illicit or prescription drug abuse:
1. What, amount, route of administration, and consequences (e.g., DUIs, other legal sequelae, and loss of relationships, jobs, and opportunities) 2. Does the patient or others think he or she has a problem? 3. Typical pattern of use 4. History of suicide ideation, gestures, or attempts while intoxicated or withdrawing 5. Longest period of sobriety 6. What facilitates sobriety? 7. Previous treatments (e.g., detoxification, rehabilitation, counseling, and Narcotics Anonymous)C. Tobacco Use:
1. Number of cigarettes or packs per day 2. Years patient has smoked 3. Cessation attemptsD. Caffeine Use:
1. Form (coffee, cola, tea, and pills) 2. Amount consumed per day 3. Cessation attemptsE. Over-the-counter drugs or "herbal" medications:
1. What, how much, purpose, frequency, side effects, and ingteractions with prescribed medication 2. Perceptions of helpfulness or efficacyV. Medical HistoryA. Past and current medical problems:
1. Illnesses, operations, and hospitalizations, especially history of open or closed head injury, birth trauma, seizure disorder, and encephalitis, meningitis, thyroid dysfunction, CardiacB. Past and current medications:
1. Dosages, blood levels, and clinical response 2. AdherenceC. Primary care physician, specialists, and phone numbers:
D. Allergies (and reactions):
E. LMP: VI. Family historyA. Psychiatric or substance use disorders:
1. Have any family members undergone psychiatric or substance abuse treatment (inpatient or outpatient), attempted or completed a suicide, had problems with drugs or alcohol, and behaved strangely? 2. Have any family members successfully used any psychotropic medications for the same or similar symptoms? 3. Family attitudes toward mental illnessB. Pertinent medical disorders in blood relatives (e.g., seizure disorder or thyroid disease):
VII. Developmental historyA. Developmental milestones and family of origin:
1. Information about mother's pregnancy and delivery 2. Were developmental milestones reached as expected? 3. Childhood temperament and important family events (e.g., death, separation, and divorce) 4. Information about early experiences and relationships (e.g., school experiences, academic performance, delinquency, family of origin relationships, family stability, early sexual experiences, and history of abuse or neglect)
B. Important cultural or religious influences:
Values, beliefs, or framework for meaningC. Educational history:

D. Occupational and military history:
1. Number and types of jobs; reasons for termination 2. Highest rank attained; conditions of discharge 3. History of disciplinary problems or combatE. Relavent Legal history:
VIII. Current Social SituationA. Living arrangements:
(e.g., where, with whom, for how long, how stable, and how satisfactory or desirable)B. Employment:
(e.g., where, for how long, how stable, and how satisfactory or desirable)C. Financial:
(e.g., current source of income, how stable, and how adequate)D. Insurance coverage:
E. Support system(s):
F. Past and present levels of functioning
1. Marriage, parenting, and work 2. Patient strengths and strategies used to manage stress, resources, or positive memories (draw a line and place important positive memories and events) 3. Current functional deficits (e.g., activities of daily living, task performance, and relationships)IX. Violence historyA. To self
1. What, when, where, how, why; warning signs or symptoms, triggers, and consequences 2. How intense, specific, and controllable is current ideation
B. To others or property
1. What, when, where, how, why; warning signs or symptoms, triggers, and consequences 2. How intense, specific, and controllable is current ideationC. Current access to weapons
1. What, where, why; plan for use; plan for disposition of weapon 2. How will disposition of weapons be verified?X. Psychiatric review of systems (ROS):
A. Includes all symptoms not just those part of the current episode or presentation B. May have to ask specific questions about the presence or absence of these symptoms
"Are you now or have you ever had any of the following...A. Anxiety symptoms
Shortness of breath, heart palpitations, panic attacks, sweating, flushing, hyperventilation, sense of doom, fear of death or collapse, cold or clammy skin, and tingling sensations in the extremities.B. Mood symptoms
Sadness, irritability, anergia,fatigue, lethargy, tearfulness,increased or decreased appetite or energy, changes in sleep or libido, suicide ideation, homocide ideation, hypomania (e.g., spending sprees, increased energy, and religious preoccupation beyond baseline), and feelings of hopelessness, helplessness, or worthlessnesC. Psychotic or cognitive symptoms
Hallucinations, delusions,thought insertion, thoughtnblocking, thought broadcasting, flight of ideas, hyperreligiosity, tangentially, looseness of associations, and circumstantiality
~OBJECTIVE~
*Vital Signs
Height:
Weight:
BMI:
Temp (C):
Pulse:
B/P:
Resp:
SPO2:
Pain:
*Labs

*Test Results
XI. Physical Exam
General:Awake, alert, oriented, well groomed
HEENT: PERRLA, Normocephalic, Hair short brown, no visible or palpable abnormalities, normal dentition, oropharynx clear, mucous membranes pink, hearing intact.
Neck: Supple, no thyromegaly, no JVD, no cervical mass of lymphadenopathy
CV: RRR, (-) for murmurs, gallop, or peripheral bruits, peripheral pulses 3+
Hematologic: (-) Bruising or petechia
Chest: CTA, normal effort, no adventitious sounds
Abdomen: Soft, BS +, ND, NT, no hepatoslenomegaly or palpable mass. Negative for abdominal or thoracic bruits
GI/GU: Continent, Flat Abdomen, denies stomach pain, heart burn, bloating, or nausea
Extremities/Skin: Warm, dry, intact, no edema, no lesions, acne, rash, excoriations, or jaundice, capillary refill <2 seconds
Musculoskeletal: Ambulatory, normal gait, DTR’s intact, normal strength, Full ROM
Cranial nerves: II – XII intactXII. Mental status examination (MSE)Informal: begins immediately on contact with the patient and includes an informal assessment of the patient's characteristics 1. Appearance 2. Manner of relating 3. Use of language 4. Mood and affect 5. Content of Speech 6. Perceptions 7. Abstracting ability 8. Judgment 9. InsightFormal: focused, structured assessment of the patient's characteristics
1. Appearance: overall appearance, dress, grooming
2. Attitude: attitude toward examiner (e.g., hostile, cooperative, evasive)
3. Behavior and psychomotor activity: gait, carriage, posture, activity level
4. Speech: Rate, amount, tone,impairment, aphasia
5. Mood and affect: a. Mood (i.e., how the patient reports feeling) in relation to affect (i.e., emotional expression observed by the therapist) b. Depth and range of emotional expression
6. Perception:
a. Hallucinations: i. Auditory ii. Visual iii. Gustatory: taste (temporal lobe dysfunction?) iv. Olfactory: smell (temporal lobe dysfunction?) v. Tactile: Skin sensations (alcohol withdrawal and intoxication?) vi. Kinesthetic: feeling movement when none occurs vii. Hypnagogic: occurs while falling asleep viii. Hypnopompic: occurs while waking up
b. Illusions: misinterpretations of actual sensory stimuli
c. Depersonalization: feels detached and views self as unreal
d. Derealization: experiences objects and persons outside of self as unreal
7. Thought process: The pattern of a patient's speech allows the therapist to observe the quality of the thought process, including its flow, logic, and assocations. Abnormalities include the following: i. Loose associations (LOAs) ii. Tangentiality iii. Circumstantiality iv. Thought blocking (TB) v. Thought insertion (T) vi. Flight of ideas (FOAs) vii. Perseveration viii. Echolalia
8. Content of thought:
a. Delusions: i. Paranoid or persecutory ii. Grandiose iii. Nihilistic iv. Somatic v. Bizarre
b. Ideas of reference:
c. Obsessions:
d. Suicidal thoughts:
e. Homicidal thoughts:
9. Judgment:
10. Insight: a. Must assess whether a person is aware of a problem, the cause of the problem, and what type of help is needed to address the problem
11. Cognition: A formal MSE measures the ability of the brain to function by assessing the following cognitive functions:
i. Consciousness: AOx4, alert, confused, drowsy, somnolent, obtunded, delirious, stuporous, and comatose
ii. Orientation: knows who he or she is, where he or she is, and what day it is
iii. Memory: can remember what was eaten for breakfast today; has remote memory for long-past events
iv. Recall: can recall three objects after 5 minutes
v. Registration: can name three objects immediately
vi. Attention: can spell world forward and backward
vii. Calculation: can do serial 7's or count backward from 20
viii. Language: can name items, repeat a phrase, follow simple commands, read, write, and copy a design~ASSESSMENT~
XIII. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) differential diagnosis
A. On a single axis, lists the principal psychiatric, neurodevelopmental, neurocognitive, and other disorders requiring further assessment1. Include treatment options
2. Patient input regarding options
3. Obstacles to treatment
4. ICD-10 codes before the disorder name

B. Includes so-called "rule-out' and/or "provisional" diagnosesICD-10 codes are listed before each disorder nameXVI.Case formulationA. Presents a brief summary of the patient and rationalizes the diagnoses 1. Minimal identifying data, including past diagnosis 2. Abbreviated recapitulation of presenting symptoms, onset, and course 3. Draws from all sections of the database as needed B. Outlines the contributing factors, precipitants, and stressors C. Summarizes the logic behind the differential diagnoses~PLAN~
XIV. Treatment plan (Devise plan from assessment data and include rationales with references for decisions)
A. Biological
1. Medications (e.g., name, dose, route, for what purpose, and patient's level of understanding of medication education)
2. Diagnostic tests (e.g., where, when, and who will administer)
3. Referrals for primary care
B. Psychological
1. Therapeutic modalities to be used and with what focus
a. Individual psychotherapy?
b. Group psychotherapy?
c. Family therapy?
d. Case management?
e. Holistic options?
f. Complimentary therapies?
C. Social
1. Support or self-help groups
2. Mobilization of family resources
3. Vocational rehabilitation
4. Financial planning
D. Strengths
1. Overt identification of patient strengths, values, and beliefs to support or draw from in implementing the identified treatment planI have read and agree to the above information - Reference - Wheeler, K. (2022). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice. Springer Publishing Company.

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