PMHNP, 6665

Assessing Neurocognitive Disorders (Dementia and Delirium)”

See the attached for the instructions and the RUBRICS.

Due Jan 12, 2025 by 11:59pm
Points 80
Submitting a text entry box or a file upload
Attempts 0
Allowed Attempts 2

Start Assignment

Back to Week at a Glance
(https://waldenu.instructure.com/courses/145702/modules/items/5778652)

(https://waldenu.instructure.com/courses/145702/files/11208824/preview) Psychiatric notes are a way to reflect
on your practicum experiences and connect the experiences to the learning you gain from your weekly
Learning Resources. Focused SOAP notes, such as the ones required in this practicum course, are often
used in clinical settings to document patient care.

For this Assignment, you will document information about a patient that you examined during the last 4
weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record
a case presentation for this patient.

FOCUSED SOAP NOTE AND PATIENT CASE
PRESENTATION, PART 1

RESOURCES

12/18/24, 8:09 AM Week 7: Assignment 2, Part 1

https://waldenu.instructure.com/courses/145702/assignments/1905646?module_item_id=5778656 1/8

https://waldenu.instructure.com/courses/145702/modules/items/5778652

https://waldenu.instructure.com/courses/145702/files/11208824/preview

Review the Kaltura button from the Classroom Support Center (accessed via the Help button) for help
creating your self-recorded Kaltura video.
Select an adult patient that you examined during the last 4 weeks who presented with a disorder other
than the disorder present in your Week 3 Case Presentation.
Create a Focused SOAP Note on this patient using the template provided in the Learning Resources.
There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment
expectations.
Please Note:

All SOAP notes must be signed, by your Preceptor.
Note: Electronic signatures are not accepted.
When you submit your note, you should include the complete focused SOAP note as a Word
document and PDF/images of the completed assignment signed by your Preceptor.
You must submit your SOAP note using Turnitin.
Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading
Policy.

Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to
practice your presentation before you record.
Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
Ensure that you have the appropriate lighting and equipment to record the presentation.

THE ASSIGNMENT
Record yourself presenting the complex case for your clinical patient.

Do not sit and read your written evaluation! The video portion of the assignment is a simulation to
demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case
consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your
ability to document the complex case as you would in an electronic medical record. The written portion of the
assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent
information or including non-essential information during your case staffing consultation video.

In your presentation:

Dress professionally and present yourself in a professional manner.
Display your photo ID at the start of the video when you introduce yourself.

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES (https://waldenu.instructure.com/courses/145702/modules/items/5778660)

TO PREPARE

12/18/24, 8:09 AM Week 7: Assignment 2, Part 1

https://waldenu.instructure.com/courses/145702/assignments/1905646?module_item_id=5778656 2/8

https://waldenu.instructure.com/courses/145702/modules/items/5778660

Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the
patient’s name or any other identifying information).
Present the full complex case study. Include chief complaint; history of present illness; any pertinent past
psychiatric, substance use, medical, social, family history; most recent mental status exam; current
psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
Report normal diagnostic results as the name of the test and “normal” (rather than specific value).
Abnormal results should be reported as a specific value.
Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the
patient, using your SOAP note as a guide:

Subjective: What details did the patient provide regarding their chief complaint and symptomology to
derive your differential diagnosis? What is the duration and severity of their symptoms? How are their
symptoms impacting their functioning in life?
Objective: What observations did you make during the psychiatric assessment?
Assessment: Discuss patient mental status examination results. What were your differential
diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from
highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your
primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.
Plan: In your video, describe your treatment plan using clinical practice guidelines supported by
evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic
agents and include alternative treatments available and supported by valid research. All treatment
choices must have a discussion of your rationale for the choice supported by valid research. What
were your follow-up plan and parameters? What referrals would you make or recommend as a result
of this treatment session?
In your written plan include all the above as well as include one social determinant of health according
to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of
psychiatry and mental health. As a future advanced provider, what are one health promotion activity
and one patient education consideration for this patient for improving health disparities and inequities
in the realm of psychiatry and mental health? Demonstrate your critical thinking.
Reflection notes: What would you do differently with this patient if you could conduct the session
over? If you are able to follow up with your patient, explain whether these interventions were
successful and why or why not. If you were not able to conduct a follow up, discuss what your next
intervention would be.

BY DAY 7 OF WEEK 7
Submit your Video and Focused SOAP Note Assignment. You must submit two files for the note, including a
Word document and scanned pdf/images of completed assignment signed by your Preceptor.

SUBMISSION INFORMATION – PART 1: VIDEO SUBMISSION
To submit your video response entry:

1. Click on Start Assignment near the top of the page.
2. Next, click Text Entry and then click the Embed Kaltura Media button.

12/18/24, 8:09 AM Week 7: Assignment 2, Part 1

https://waldenu.instructure.com/courses/145702/assignments/1905646?module_item_id=5778656 3/8

PRAC_6665_Week7_Assignment2_Pt1_Rubric

3. Select your recorded video under My Media.
4. Check the box for the End-User License Agreement and select Submit Assignment for review.

SUBMISSION INFORMATION – PART 2: FOCUSED SOAP NOTE
SUBMISSION

To submit Part 2 of this Assignment, click on the following link:

Week 7 Assignment 2, Part 2
(https://waldenu.instructure.com/courses/145702/assignments/1905649)

12/18/24, 8:09 AM Week 7: Assignment 2, Part 1

https://waldenu.instructure.com/courses/145702/assignments/1905646?module_item_id=5778656 4/8

https://waldenu.instructure.com/courses/145702/assignments/1905649

Criteria Ratings Pts

5 pts

10 pts

Photo ID display and
professional attire

5 to >0.0 pts
Excellent

Photo ID is displayed.
The student is dressed
professionally.

0 pts
Fair

0 pts
Good

0 pts
Poor

Photo ID is not displayed. Student must
remedy this before grade is posted. The
student is not dressed professionally.

Time 5 to >0.0 pts
Excellent

The video does not
exceed the 8-minute
time limit.

0 pts
Fair

0 pts
Good

0 pts
Poor

The video exceeds the 8-minute time limit.
(Note: Information presented after 8
minutes will not be evaluated for grade
inclusion.)

Discuss Subjective
data:• Chief
complaint• History of
present illness (HPI)•
Medications•
Psychotherapy or
previous psychiatric
diagnosis• Pertinent
histories and/or ROS

10 to >8.0 pts
Excellent

The video
accurately and
concisely
presents the
patient’s
subjective
complaint, history
of present illness,
medications,
psychotherapy or
previous
psychiatric
diagnosis, and
pertinent histories
and/or review of
systems that
would inform a
differential
diagnosis.

8 to >7.0 pts
Good

The video
accurately
presents the
patient’s
subjective
complaint, history
of present illness,
medications,
psychotherapy or
previous
psychiatric
diagnosis, and
pertinent histories
and/or review of
systems that
would inform a
differential
diagnosis.

7 to >6.0 pts
Fair

The video
presents the
patient’s subjective
complaint, history
of present illness,
medications,
psychotherapy or
previous
psychiatric
diagnosis, and
pertinent histories
and/or review of
systems that
would inform a
differential
diagnosis, but is
somewhat vague
or contains minor
inaccuracies.

6 to >0 pts
Poor

The video presents
an incomplete,
inaccurate, or
unnecessarily
detailed/verbose
description of the
patient’s subjective
complaint, history of
present illness,
medications,
psychotherapy or
previous psychiatric
diagnosis, and
pertinent histories
and/or review of
systems that would
inform a differential
diagnosis. Or
subjective
documentation is
missing.

Discuss Objective
data:• Physical exam
documentation of
systems pertinent to
the chief complaint,
HPI, and history•
Diagnostic results,
including any labs,

10 to >8.0 pts
Excellent

The video
accurately and
concisely
documents the
patient’s physical
exam for pertinent

8 to >7.0 pts
Good

The response
accurately
documents the
patient’s
physical exam
for pertinent

7 to >6.0 pts
Fair

Documentation of
the patient’s
physical exam is
somewhat vague
or contains minor
inaccuracies.

6 to >0 pts
Poor

The response
provides incomplete,
inaccurate, or
unnecessarily
detailed/verbose
documentation of the

12/18/24, 8:09 AM Week 7: Assignment 2, Part 1

https://waldenu.instructure.com/courses/145702/assignments/1905646?module_item_id=5778656 5/8

Criteria Ratings Pts

20 pts

imaging, or other
assessments needed
to develop the
differential diagnoses

systems. Pertinent
diagnostic tests
and their results
are documented,
as applicable.

systems.
Diagnostic tests
and their results
are documented,
as applicable.

Diagnostic tests
and their results
are documented
but contain
inaccuracies.

patient’s physical
exam. Systems may
have been
unnecessarily
reviewed, or objective
documentation is
missing.Discuss results of

Assessment:•
Results of the mental
status examination•
Provide a minimum of
three possible
diagnoses in order of
highest to lowest
priority and explain
why you chose them.
What was your
primary diagnosis
and why? Describe
how your primary
diagnosis aligns with
DSM-5 diagnostic
criteria and is
supported by the
patient’s symptoms.

20 to >17.0 pts
Excellent

The video
accurately
documents the
results of the
mental status
exam. Video
presents at least
three differentials
in order of priority
for a differential
diagnosis of the
patient, and a
rationale for their
selection.
Response justifies
the primary
diagnosis and how
it aligns with DSM-
5 criteria.

17 to >15.0 pts
Good

The video
adequately
documents the
results of the
mental status
exam. Video
presents three
differentials for the
patient and a
rationale for their
selection.
Response
adequately
justifies the
primary diagnosis
and how it aligns
with DSM-5
criteria.

15 to >13.0 pts
Fair

The video presents
the results of the
mental status
exam, with some
vagueness or
inaccuracy. Video
presents three
differentials for the
patient and a
rationale for their
selection.
Response
somewhat vaguely
justifies the primary
diagnosis and how
it aligns with DSM-
5 criteria.

3 to >0 pts
Poor

The response
provides an
incomplete,
inaccurate, or
unnecessarily
detailed/verbose
description of the
results of the
mental status exam
and explanation of
the differential
diagnoses. Or
assessment
documentation is
missing.

Discuss treatment
Plan:• A treatment
plan for the patient
that addresses
chosen FDA-
approved
psychopharmacologic
agents and includes
alternative treatments
available and
supported by valid
research. The
treatment plan
includes rationales, a
plan for follow-up
parameters, and
referrals. The
discussion includes
one social
determinant of health

20 to >17.0 pts
Excellent
The video clearly and
concisely outlines an
evidence-based
treatment plan for the
patient that
addresses FDA-
approved
psychopharmacologic
agents and includes
alternative treatments
and rationale
supported by valid
research. …
Discussion includes a
clear and concise
follow-up plan and
parameters…. The

17 to >15.0 pts
Good
The video clearly
outlines an
appropriate treatment
plan without
evidence-based
discussion for the
patient that
addresses FDA-
approved
psychopharmacologic
agents and includes
alternative treatments
and rationale
supported by vague
or questionable
research. …
Discussion includes a

15 to >13.0 pts
Fair
The response
somewhat vaguely or
inaccurately outlines
a treatment plan for
the patient that
addresses
psychopharmacologic
agents without
discussion of FDA
approval and
includes vague or
inaccurate alternative
treatments with little
rationale discussed.
… The discussion is
somewhat vague or
inaccurate regarding

13 to >0 pts
Poor
The
response
does not
address the
treatment
plan or the
treatment
plan is not
appropriate
for the
assessment
and the
diagnosis.
There is no
mention of
FDA
approval for

12/18/24, 8:09 AM Week 7: Assignment 2, Part 1

https://waldenu.instructure.com/courses/145702/assignments/1905646?module_item_id=5778656 6/8

Criteria Ratings Pts

5 pts

according to the
HealthyPeople 2030,
one health promotion
activity and one
patient education
consideration for this
patient for improving
health disparities and
inequities in the
realm of psychiatry
and mental health.

discussion includes a
clear and concise
referral plan. … The
paper discussion
contains all 3
elements from the
assignment directions
including a
discussion
demonstrating critical
thinking of the case
related to the
HealthyPeople 2030
social health
determinates. Clearly
and concisely relates
discussion to the
psychiatric and
mental health field.

clear follow-up plan
and parameters….
The discussion
includes a clear
referral plan…. The
paper discussion
contains 2 of the
elements from the
assignment directions
with one being a
basic discussion of
the case related to
the HealthyPeople
2030 social health
determinates. Clearly
relates discussion to
the psychiatric and
mental health field.

the follow-up plan
and parameters….
The discussion is
somewhat vague or
inaccurate regarding
a referral plan. … The
paper discussion
contains 1 of the
required elements
from the assignment
directions which is
the HealthyPeople
2030 social health
determinates….
Somewhat vaguely or
inaccurately relates
discussion to the
psychiatric and
mental health field.

treatment
choices or
no research
supported
discussion.
Alternative
treatment
discussion
is missing.
…
Rationales
for
treatments
are missing.
… There is
no
discussion
for follow-up
and
parameters.
… There is
no
discussion
of a referral
plan. … The
paper
discussion
is missing
discussion
relating to
the
psychiatric
and mental
health field
or relates
discussion
to another
specialty
realm
including
medical co-
morbidity
illnesses.

Reflect on this case.
Discuss what you
learned and what you
might do differently.

5 to >4.0 pts
Excellent

Reflections are
thorough, thoughtful,
and demonstrate
critical thinking.

4 to >3.5 pts
Good

Reflections
demonstrate
critical thinking.

3.5 to >3.0 pts
Fair

Reflections are
somewhat general or
do not demonstrate
critical thinking.

3 to >0 pts
Poor

Reflections are
incomplete,
inaccurate, or
missing.

12/18/24, 8:09 AM Week 7: Assignment 2, Part 1

https://waldenu.instructure.com/courses/145702/assignments/1905646?module_item_id=5778656 7/8

Total Points: 80

Criteria Ratings Pts

5 pts

Presentation style 5 to >4.0 pts
Excellent

Presentation style
is exceptionally
clear, professional,
and focused.

4 to >3.5 pts
Good

Presentation
style is clear,
professional, and
focused.

3.5 to >3.0 pts
Fair

Presentation style
is mostly clear,
professional, and
focused

3 to >0 pts
Poor

Presentation style is
unclear,
unprofessional,
and/or unfocused.

12/18/24, 8:09 AM Week 7: Assignment 2, Part 1

https://waldenu.instructure.com/courses/145702/assignments/1905646?module_item_id=5778656 8/8

[removed]

NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar

INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY

If you are struggling with the format or remembering what to include, follow the
Focused SOAP Note Evaluation Template

AND
the Rubric
as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. After reviewing full details of the rubric, you can use it as a guide.

In the
Subjective section, provide:

· Chief complaint

· History of present illness (HPI)

· Past psychiatric history

· Medication trials and current medications

· Psychotherapy or previous psychiatric diagnosis

· Pertinent substance use, family psychiatric/substance use, social, and medical history

· Allergies

· ROS

Read rating descriptions to see the grading standards!

In the
Objective section, provide:

· Physical exam documentation of systems pertinent to the chief complaint, HPI, and history

· Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.

Read rating descriptions to see the grading standards!

In the
Assessment section, provide:

· Results of the mental status examination,

presented in paragraph form.

· At least three differentials with supporting evidence. List them from top priority to least priority. Compare the
DSM-5-TR diagnostic criteria for each differential diagnosis and explain what
DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis.

Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case

·
Read rating descriptions to see the grading standards!

Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (

demonstrate critical thinking beyond confidentiality and consent for treatment

!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

(The FOCUSED SOAP psychiatric evaluation is typically the
follow-up visit patient note. You will practice writing this type of note in this course. You will be focusing more on the symptoms from your differential diagnosis from the comprehensive psychiatric evaluation narrowing to your diagnostic impression. You will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)

EXEMPLAR BEGINS HERE

Subjective:

CC (chief complaint): A
brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:

N.M. is a 34-year-old Asian male presents for medication management follow up for anxiety. He was initiated sertraline last appt which he finds was effective for two weeks then symptoms began to return.

P.H., a 16-year-old Hispanic female, presents for follow up to discuss previous psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications as we deferred until further testing and screening was conducted.

Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.

Paint a picture of what is wrong with the patient. First what is bringing the patient to your follow up evaluation? Document symptom onset, duration, frequency, severity, and impact. What has worsened or improved since last appointment? What stressors are they facing? Your description here will guide your differential diagnoses into your diagnostic impression. You are seeking symptoms that may align with many
DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies:
Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx:
Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns

ROS: Cover all body systems that may help you include or rule out a differential diagnosis. Please note: THIS IS DIFFERENT from a physical examination!

You should list each system as follows:
General:
Head:
EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Objective:

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

Assessment:

Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.

He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.

Diagnostic Impression:
You must begin to narrow your differential diagnosis to your diagnostic impression. You must explain how and why (your rationale) you ruled out any of your differential diagnoses. You must explain how and why (your rationale) you concluded to your diagnostic impression. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection a discussion related to legal/ethical considerations (
demonstrating critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

Case Formulation and Treatment Plan

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions including psychotherapy and/or psychopharmacology, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.
*See an example below. You will modify to your practice so there may be information excluded/included. If you are completing this for a practicum, what does your preceptor document?

Risks and benefits of medications are discussed including non- treatment. Potential side effects of medications discussed (be detailed in what side effects discussed). Informed client not to stop medication abruptly without discussing with providers. Instructed to call and report any adverse reactions. Discussed risk of medication with pregnancy/fetus, encouraged birth control, discussed if does become pregnant to inform provider as soon as possible. Discussed how some medications might decreased birth control pill, would need back up method (exclude for males).

Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. Discussed how drugs/alcohol affect mental health, physical health, sleep architecture.

Initiation of (list out any medication and why prescribed, any therapy services or referrals to specialist):

Client was encouraged to continue with case management and/or therapy services (if not provided by you)

Client has emergency numbers: Emergency Services 911, the Client’s Crisis Line
1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)

Reviewed hospital records/therapist records for collaborative information; Reviewed PMP report (only if actually completed)

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (this relates to informed consent; you will need to assess their understanding and agreement)

Follow up with PCP as needed and/or for:

Labs ordered and/or reviewed (write out what diagnostic test ordered, rationale for ordering, and if discussed fasting/non fasting or other patient education)

Return to clinic:

Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care.

References (move to begin on next page)

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

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