Depressive Disorder and Generalized Anxiety Disorder
Discipline: Nursing
Type of Paper: Essay (any type)
Academic Level: Master's
Paper Format: APA
Question
SOAP Note Assignment
This SOAP note should be
written on 14-years-old
African American girl diagnosed with Major depressive disorder and generalized
anxiety disorder. It should be written by an experienced
professional psychiatric nurse practitioner SOAP note writer. Please do not
assign this writing to a beginner and inexperienced writer.
Overview
PMHNP’s must document information to substantiate
assessments, diagnoses, and plans of care. This facilitates safe patient care
and appropriate transition management. In this assignment, you will create a
SOAP note and discuss what you learned through a specific patient encounter.
Do not include any identifying patient information on your
assignment.
Purpose
The purpose of this assignment is to facilitate the
learner’s ability to create a comprehensive SOAP note.
Assignment outcome
At the conclusion of this assignment, the learner will be
able to:
· Present
a comprehensive SOAP note regarding a specific patient encounter
· Identify
a particular piece of learning that took place via this specific patient
encounter
Directions
Select a patient encounter in which you learned something
new. Create a fully-formed SOAP note regarding this patient encounter.
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Soap Note Virtual Case Submission Rubric |
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Criteria |
20 Points |
19 Points |
18 Points |
0 Points |
|
|
Subjective |
Communicates a clear & precise assessment
data supported with subjective findings. This should include but not limited to
biological, psychological, sociocultural, spiritual, ethnic, and family
factors. |
Communicates an assessment but may be missing 1-2
important piece of data |
Communicates a brief & vague assessment while missing
key important details of the assessment data |
No paper submitted or substantial content missing |
/20 |
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Objective |
Communicates a clear & precise assessment
data supported with objective findings. This should include but not limited to Mental
Status Exam, biological, psychological, sociocultural, spiritual, ethnic, and
family factors. |
Communicates an assessment but may be missing 1-2
important piece of data |
Communicates a brief & vague assessment while missing
key important details of the assessment data |
No paper submitted or substantial content missing |
/20 |
|
Assessment |
Thoroughly describes all relevant differential
diagnoses and the actual DSM-V diagnosis with ICD 10 codes. |
Describes differential diagnoses but omits one that should
be considered |
Describes differential diagnoses but omits more than one
that should be considered |
No paper submitted or content missing |
/20 |
|
Plan |
Develops and provides a clearly written
treatment plan, including relevant health promotion and patient education
information. Clearly defines and delineates the levels of evidence that
support the treatment plan. |
Develops a clear set of written orders but omits an
important order for the diagnosis or outdated approach not supported by
evidence. Covers educational topics and health promotion, but no plan is
developed. |
Develops and provides a brief set of orders for the
treatment plan with more than one omission and lacks evidential support.
Health promotion and patient education are substantially lacking or not
covered. |
No paper submitted or content missing |
/20 |
|
Criteria |
10 Points |
8 Points |
6 Points |
0 Points |
/10 |
|
Grammar, spelling, and punctuation |
There are no errors in grammar, spelling, and
punctuation |
There are a few minor errors in grammar, spelling, and
punctuation that do not detract from the meaning |
There are multiple errors in grammar, spelling, and
punctuation that detract from the meaning |
There are major errors in grammar, spelling, and
punctuation that do not reflect scholarly writing |
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APA and references |
The paper meets APA format guidelines and/or all
references are peer reviewed, relevant, scholarly and contemporary, up to 5
years. |
There are minor APA format errors and/or references meet
two requirements of relevant, scholarly or contemporary, up to 5 years. |
There are multiple errors in format and/or references meet
one requirement of relevant, scholarly or contemporary |
There are significant errors in format and/or references
meet one requirement of relevant, scholarly or contemporary |
/10 |
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Total Points Possible = 100 |
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