NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Week (enter week #): (Enter assignment title)

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6665: PMHNP Care Across the Lifespan I

Faculty Name

Assignment Due Date

Subjective:

CC (chief complaint):

HPI:

Substance Current Use:

Medical History:

· Current Medications:

· Allergies:

· Reproductive Hx:

ROS:

· GENERAL:

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:

Diagnostic Impression:

Reflections:

Case Formulation and Treatment Plan: 

References

ANSWER SUMMARY

A comprehensive focused SOAP (Subjective, Objective, Assessment, Plan) psychiatric evaluation is a standard format used by mental health professionals to document and communicate information about a patient’s mental health status and treatment plan.

The subjective portion of the evaluation includes information provided by the patient about their symptoms, concerns, and personal and medical history. This may include details about the patient’s mood, thoughts, behaviors, and any changes they have noticed in their functioning.

The objective portion of the evaluation includes information gathered by the mental health professional through observation and testing. This may include the results of physical examinations, laboratory tests, and psychological assessments.

The assessment portion of the evaluation involves the mental health professional’s evaluation of the patient’s mental health status, including any diagnoses and treatment recommendations.

The plan portion of the evaluation outlines the specific steps that will be taken to address the patient’s mental health concerns, including any medications or therapy that may be prescribed, and any referrals to other specialists or support services as needed.

Overall, a comprehensive focused SOAP psychiatric evaluation provides a detailed and structured overview of a patient’s mental health status and treatment plan, and serves as a useful tool for coordinating care and monitoring progress.

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