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Select a child or adolescent patient that you examined during the last 3 weeks who presented with a disorder for which you have not already created a Focused SOAP Note in Weeks 3 or 7.
Tipic: BULEMIA NERVOSA
Please see the rubrics attached.
Due Jan 26 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/5778673)
(https://waldenu.instructure.com/courses/145702/files/11208824/preview)
For this Assignment, you will document information about a patient that you examined during the last 3
weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record
a case presentation for this patient. Be sure to incorporate any feedback you received on your Week 3 and
Week 7 case presentations into this final presentation for the course.
FOCUSED SOAP NOTE AND PATIENT CASE
PRESENTATION, PART 1
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCE (https://waldenu.instructure.com/courses/145702/modules/items/5778680)
1/3/25, 7:36 PM Week 9: Assignment 2, Part 1
https://waldenu.instructure.com/courses/145702/assignments/1905659?module_item_id=5778676 1/8
https://waldenu.instructure.com/courses/145702/modules/items/5778673
https://waldenu.instructure.com/courses/145702/modules/items/5778673
https://waldenu.instructure.com/courses/145702/files/11208824/preview
https://waldenu.instructure.com/courses/145702/files/11208824/preview
https://waldenu.instructure.com/courses/145702/modules/items/5778680
Review the Kaltura button from the Classroom Support Center (accessed via the Help button) for help
creating your self-recorded Kaltura video.
Select a child or adolescent patient that you examined during the last 3 weeks who presented with a
disorder for which you have not already created a Focused SOAP Note in Weeks 3 or 7. (For instance, if
you selected a patient with anorexia nervosa in Week 7, you must choose a patient with another type of
disorder for this week.)
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.
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.
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
TO PREPARE
THE ASSIGNMENT
1/3/25, 7:36 PM Week 9: Assignment 2, Part 1
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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 their 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.
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.
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.
BY DAY 7 OF WEEK 9
SUBMISSION INFORMATION – PART 1: VIDEO SUBMISSION
1/3/25, 7:36 PM Week 9: Assignment 2, Part 1
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PRAC_6665_Week9_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.
To submit Part 2 of this Assignment, click on the following link:
Week 9 Assignment 2, Part 2
(https://waldenu.instructure.com/courses/145702/assignments/1905661)
SUBMISSION INFORMATION – PART 2: FOCUSED SOAP
NOTE SUBMISSION
1/3/25, 7:36 PM Week 9: Assignment 2, Part 1
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https://waldenu.instructure.com/courses/145702/assignments/1905661
https://waldenu.instructure.com/courses/145702/assignments/1905661
Criteria Ratings Pts
5 pts
5 pts
10 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
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Criteria Ratings Pts
20 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.
1
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
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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.
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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.
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