Clinical SOAP Note on Autism Spectrum Disorder

Every other week students will choose one patient encounter to submit a Follow-up SOAP note for review.

Follow the rubric to develop your SOAP notes for this term.

The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.

All work should be original and submitted as a Word document unless otherwise indicated in the assignment instructions. ALL assignments need to be APA 7 format and accompanied title page in APA 7th edition format in order that the work would be properly identified for the student, the course, and the assignment. Work submitted without a title page will receive a grade of 0.

Complete this assignment and submit it to this assignment dropbox by Sunday at 11:59 pm CT.

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Course information

NU674 Psychiatric Mental Healthcare II

Course Description

This purpose of this course is to provide students further studies related psychiatric/mental health care management of patients across the life span to include underlying acute and chronic psychiatric/mental health disorders. Clinical opportunities will be utilized to apply concepts in primary and acute care settings with adults and families.

Program: Graduate Nursing

Semester Credit Hours: 4.0

Contact Hours: 30/0/90/120 (Lecture Hours/Lab Hours/Clinical Hours/Total Hours)

Program Outcomes

Students are expected to meet all the core MSN program outcomes as well as the Psychiatric Mental Health program outcomes.

Upon completion of their program, the student should be able to:

1. Demonstrate critical thinking and holistic caring as an advanced practice

2. Analyze scientific literature for application to selected diagnoses and treatment

3. Synthesize ethical principles into the management and evaluation of healthcare delivery concerns in culturally diverse care settings.

4. Articulate a personal philosophy and framework acknowledging professional and accrediting agency competencies relating to the role and scope of practice of the psychiatric mental health nurse practitioner.

5. Implement the role of the psychiatric mental health nurse practitioner in selected clinical settings

Course Learning Objectives

By the end of this course, you will be able to:

3. Apply knowledge, with mentor supervision and minimal prompting, of chronic and acute psychiatric mental health disorders using the current edition of the Diagnostic and Statistical Manual for Mental Disorders diagnostic criteria to assess, diagnose and manage the patient populations across the lifespan including a focus on vulnerable populations at risk for mental health disorders.

4. Integrate, with mentor supervision and minimal prompting, complete mental health assessment, interview, history and physical exam data collection with the knowledge of pathophysiology and psychopathology of psychiatric mental health disorders across the life span to form differential diagnoses and implement therapeutic, patient-centered treatment plans and interventions for patient populations across the lifespan.

5. Merge, with mentor supervision and minimal prompting, traditional and complementary pharmacological/non-pharmaceutical interventions into the treatment and management of psychiatric mental health disorders for patient populations across the lifespan.

6. Examine, evaluate, and demonstrate, with mentor supervision and minimal prompting, professional development in the role of the nurse practitioner in the diagnosis and management of health and wellness as well as acute and chronic psychiatric mental health disorders illnesses for patient populations across the lifespan as a member of an interprofessional team.

7. Integrate, with mentor supervision and minimal prompting, cultural, spiritual, and social competencies into therapeutic patient-centered treatment plans in connection with evidence-based findings to the diagnosis and management of individuals, groups and families across the lifespan with acute, complex, and chronic psychiatric mental health disorders illnesses for patient populations across the lifespan as a member of an interprofessional team.

8. Analyze, with mentor supervision and minimal prompting, professional values and core ethical/legal standards into the practice of the Psychiatric Mental Health Nurse Practitioner role with relation to patient/staff safety, quality indicators, and health outcome improvement in the delivery of quality psychiatric mental health care to patients.

9. Identifies, with mentor supervision and minimal prompting, the highest level of professionalism and accountability for the PMHNP role for transition into clinical practice.

Resources

Required

American Psychological Association. (2019). Publication manual of the American Psychological Association (7th ed.). Washington, DC: APA Press. ISBN 9781433832161

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders text revision (5th ed. -TR) (DSM-5 -TR). APA. ISBN: 978-0-89042-576-3

Carlat, D. J. (2023). The psychiatric interview (5th ed.). Philadelphia, PA: Wolters Kluwer. ISBN: 9781975212971

Johnson, K., & Vanderhoef, D. (2016). Psychiatric mental health nurse practitioner review manual (4th ed.). Silver Spring, MD: American Nurses Association. ISBN: 978-1-935213- 79-6

Joseph Boland, Verduin, M. L., Ruiz, P., Arya Shah, & Sadock, B. J. (2021). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (12th ed.). Philadelphia, PA: Lippincott Williams, and Wilkins. ISBN: 9781975145569

Recommended

Dulcan’s Textbook of Child and Adolescent Psychiatry (3rd ed.) by Dulcan, Mina K. M.D. ISBN 9781615373277, 1615373276

Stahl, S. M. (2022). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (5th ed.). Cambridge University Press. ISBN: 978-1-108-97163-8

Stahl, S. M. (2021). Prescriber’s guide: Stahl’s essential psychopharmacology (7th ed.). Cambridge University Press. ISBN: 978-1-108-97163-8

The post Clinical SOAP Note on Autism Spectrum Disorder first appeared on College Essays Cafe.

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