Walden University

College of Nursing | PMHNP Program

PRAC 6665: PMHNP Care Across the Lifespan I

Practicum Assignment: Psychiatric SOAP Note with Focused Case Analysis

Assignment Overview

Psychiatric-mental health nurse practitioners (PMHNPs) are expected to deliver safe, evidence-informed, and culturally competent psychiatric care to patients across the full developmental lifespan. The clinical documentation skills you develop in this practicum are not simply academic exercises — they are the professional standard your preceptors, licensure boards, and future employers will evaluate. Consistent, complete, and legally defensible SOAP notes are the backbone of quality psychiatric practice.

In PRAC 6665, each practicum week requires you to document and critically analyze a real or simulated patient encounter drawn from your approved clinical site. Week 4 focuses on applying a comprehensive psychiatric SOAP note format to a patient presenting with a primary psychiatric complaint, then extending that documentation into a focused evidence-based clinical analysis. Your work must integrate your clinical findings with current DSM-5-TR diagnostic criteria, psychopharmacological evidence, trauma-informed care principles, and relevant social determinants of mental health.

This assignment develops three interconnected competencies that ANCC PMHNP certification and NONPF NP Core Competencies require: clinical reasoning, diagnostic precision, and evidence-based prescribing judgment across the lifespan.

Course Learning Outcomes Addressed

Upon successful completion of this assignment, you will demonstrate the ability to:

1. Conduct and document a comprehensive psychiatric mental status examination (MSE) and patient history using a standardized PMHNP SOAP note framework.
2. Apply DSM-5-TR diagnostic criteria accurately to formulate one primary and at least one differential psychiatric diagnosis with supporting clinical rationale.
3. Develop a safe, evidence-based, and patient-centered pharmacological and non-pharmacological treatment plan appropriate to the patient’s lifespan stage (pediatric, adult, or geriatric).
4. Integrate trauma-informed care, cultural humility, and relevant social determinants of health (SDOH) into clinical reasoning and the care plan.
5. Demonstrate compliance with Walden University’s practicum documentation standards, HIPAA regulations, and APA 7th edition academic formatting requirements.

Background and Context

PMHNP students at Walden University are required to complete practicum hours with an approved preceptor at a clinical site that sees patients with a broad range of psychiatric conditions. PRAC 6665 emphasizes foundational PMHNP competencies before you advance to the more complex lifespan and specialty presentations in PRAC 6670 and beyond. The patients you encounter in your practicum will vary significantly in age, diagnosis, cultural background, and complexity — and your ability to document those encounters clearly and completely is a core professional responsibility.

The SOAP note format (Subjective, Objective, Assessment, Plan) is the clinical standard in psychiatric NP practice. The Walden PMHNP SOAP note template incorporates all required elements for psychiatric encounters, including a structured Mental Status Examination, a DSM-5-TR aligned diagnostic formulation, a risk assessment, and a treatment plan with pharmacological and therapeutic components. You are expected to use this template — not a generic medical SOAP format — for all practicum documentation assignments in this course.

The additional 1,000–1,200-word evidence-based discussion section asks you to step back from the documentation itself and demonstrate your clinical reasoning at a graduate level. You are expected to justify your diagnostic and treatment decisions using current peer-reviewed literature (published within the last five years where possible), explain how lifespan considerations shaped your plan, and reflect critically on at least one ethical or cultural complexity present in the case.

Assignment Instructions

Your submission must consist of two clearly delineated components presented as a single Microsoft Word document:

Component 1: Psychiatric SOAP Note

Using the Walden University PMHNP SOAP Note Template (provided in the course resources), document a psychiatric patient encounter from your current practicum site. The patient must have a presenting psychiatric complaint, not a purely medical one. If you do not yet have access to a practicum site, you may use the approved Shadow Health or i-Human simulated patient case designated for Week 4 — notify your Instructor before proceeding.

Your SOAP note must include each of the following sections, fully completed:

S — Subjective

• Chief Complaint (CC): Patient’s reason for the visit in their own words.
• History of Present Illness (HPI): Onset, duration, location (if applicable), severity, associated symptoms, modifying factors, and context, following the OLDCARTS or LOCATES framework.
• Past Psychiatric History: Prior diagnoses, inpatient hospitalizations, outpatient treatment, history of self-harm or suicidal/homicidal ideation and attempts, electroconvulsive therapy (ECT) history.
• Past Medical History (PMH): Chronic medical conditions, surgeries, relevant physical health issues.
• Current Medications: All psychiatric and non-psychiatric medications, dosages, frequency, prescriber, and adherence level.
• Allergies: Include type of reaction; list NKDA if applicable.
• Family Psychiatric and Medical History: Mental health diagnoses and medical conditions in first-degree relatives.
• Social History (SH): Living situation, education, employment, relationship status, support system, cultural/spiritual background, substance use history (CAGE-AID or AUDIT-C screening results if applicable), trauma history (ACE score or relevant history), legal history, sexual history where clinically relevant.
• Review of Systems (ROS): Psychiatric and pertinent medical systems reviewed; note positives and negatives.

O — Objective

• Vital Signs: Include weight, BMI, blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation where available.
• Physical Examination Findings: Document any relevant physical exam findings; note if full physical exam not performed and reason.
• Mental Status Examination (MSE): Must include all standard components:
  • Appearance (grooming, hygiene, eye contact, psychomotor activity)
  • Behavior and Attitude (cooperative, guarded, hostile, etc.)
  • Speech (rate, rhythm, volume, tone, latency)
  • Mood (patient-reported) and Affect (clinician-observed: range, appropriateness, reactivity)
  • Thought Process (linear, tangential, circumstantial, flight of ideas, thought blocking, loosening of associations)
  • Thought Content (suicidal ideation with plan/intent, homicidal ideation, paranoia, obsessions, compulsions, delusions — type and content)
  • Perceptual Disturbances (auditory, visual, olfactory, or tactile hallucinations)
  • Cognitive Function (orientation x4, estimated intellectual functioning, insight, judgment, concentration, memory)
• Relevant Diagnostic or Laboratory Results: Recent labs (metabolic panel, thyroid function, CBC, lipid panel if on antipsychotics or mood stabilizers), urine drug screen, validated rating scales (PHQ-9, GAD-7, Columbia Suicide Severity Rating Scale, AIMS, PANSS, MDQ, or others as clinically appropriate).

A — Assessment

• Primary Psychiatric Diagnosis: State using full DSM-5-TR diagnostic criteria and specifiers (e.g., Major Depressive Disorder, Recurrent, Moderate, with Anxious Distress). Include ICD-10-CM code.
• Differential Diagnoses: Provide a minimum of two differential diagnoses with brief clinical justification for inclusion and explanation of why each was not selected as the primary diagnosis at this time.
• Risk Assessment: Document risk level (low, moderate, high) for suicide and homicide; include protective factors. Use Columbia-Suicide Severity Rating Scale (C-SSRS) or equivalent validated tool.
• Formulation: A brief (3–5 sentence) integrative biopsychosocial formulation that synthesizes the patient’s presentation, relevant history, SDOH, and diagnostic rationale.

P — Plan

• Pharmacological Interventions: List any medications prescribed, continued, adjusted, or discontinued. For each, include: drug name (generic and brand), dose, route, frequency, rationale based on evidence, relevant black box warnings, monitoring parameters (labs, vital signs, side effects), and patient education provided.
• Non-Pharmacological Interventions: Psychotherapy modality recommended or initiated (e.g., CBT, DBT, motivational interviewing), rationale, referrals to outpatient therapy, community mental health, or social services.
• Safety Planning: Document safety plan if applicable; note if patient signed a safety contract or crisis line information was provided (988 Suicide and Crisis Lifeline).
• Patient and Family Education: Topics covered in the session; cultural and health literacy considerations addressed.
• Follow-Up: Specific timeframe for next appointment; conditions that would prompt earlier return or emergency referral.
• Lifespan Considerations: Specific note on how the patient’s developmental stage (pediatric, adult, geriatric) influenced diagnostic or treatment decisions. This is a required element in PRAC 6665.
• Preceptor Attestation Placeholder: Include a line for preceptor name, credentials, and signature verifying that the encounter was supervised.

Component 2: Evidence-Based Clinical Discussion (1,000–1,200 Words)

Following your SOAP note, write a focused evidence-based discussion that addresses the clinical reasoning behind your documentation. This section must be written in graduate-level academic prose, fully cited in APA 7th edition format, and supported by a minimum of four peer-reviewed sources published within the last five years (exceptions may be made for foundational texts such as the DSM-5-TR or APA Practice Guidelines).

Your discussion must address all four of the following areas:

6. Diagnostic Justification: Explain why your primary diagnosis is the most clinically appropriate choice for this patient. Reference the specific DSM-5-TR criteria met and clearly distinguish your primary diagnosis from the two differentials you listed in the SOAP note. Discuss any diagnostic challenges specific to the patient’s age group (e.g., distinguishing ADHD from bipolar disorder in adolescents, or early dementia from late-onset depression in geriatric patients).
7. Pharmacological and Treatment Plan Rationale: Justify each pharmacological decision using current evidence, FDA-approved indications, and any age-specific prescribing guidelines (pediatric weight-based dosing, Black Box Warnings for antidepressants in patients under 25, QTc monitoring for geriatric patients, renal/hepatic adjustments). Identify at least one evidence-based non-pharmacological intervention and explain its role in the overall treatment plan.
8. Lifespan, Cultural, and Trauma-Informed Considerations: Describe how the patient’s developmental stage, cultural background, and trauma history were factored into your clinical approach. Reference current evidence on trauma-informed psychiatric care and any cultural adaptations to assessment or treatment that were considered.
9. Ethical and Legal Dimensions: Identify at least one ethical or legal issue relevant to this case (e.g., informed consent, confidentiality and its limits with minors, mandated reporting, scope of practice as an NP student, involuntary commitment criteria in your state). Discuss how you navigated or would navigate this issue in clinical practice.

Submission Requirements and Formatting Guidelines

Document Structure

• Submit as a single Microsoft Word document (.docx) via the Blackboard assignment submission link before the end of Week 4 (Sunday by 11:59 PM ET).
• Title Page: APA 7th edition format — student name, course code and name, assignment title, instructor name, and submission date.
• SOAP Note: Use the Walden PMHNP SOAP Note Template. Do not alter section headings. All fields must be completed; write ‘N/A’ with a brief rationale if a section is genuinely not applicable.
• Discussion Section: Follows the SOAP note; clearly labeled ‘Evidence-Based Clinical Discussion.’ Must be 1,000–1,200 words, not including references.
• References Page: APA 7th edition; minimum four peer-reviewed sources (last five years preferred); DSM-5-TR and practice guidelines are acceptable as additional references.
• Running Head: Not required in APA 7th edition for student papers; use page numbers only.
• Font and Spacing: 12-point Times New Roman or Calibri; double-spaced throughout; 1-inch margins.

De-identification and HIPAA Compliance

All patient information must be fully de-identified in accordance with HIPAA’s Safe Harbor method. Replace all identifying information with fictional details (patient initials only, no last names; change age by no more than five years; use ‘local community hospital’ rather than a named facility). Your submission may be reviewed by Turnitin; de-identification is both a legal and an ethical obligation in practicum coursework.

Practicum Documentation Log

This encounter must also be logged in Meditrek (or the approved platform for your cohort) under the correct encounter type. Failure to log the encounter in Meditrek by the submission deadline will result in the encounter not being counted toward your required practicum hours, regardless of whether your written assignment is submitted on time.

Sample Answer Excerpt (Illustrative Only — Not for Direct Submission)

Illustrative Sample — Diagnostic Justification Section (Discussion Component):

Patient J.M. is a 34-year-old Hispanic female presenting with a three-month history of depressed mood, anhedonia, hypersomnia, psychomotor retardation, passive suicidal ideation without a plan, and a PHQ-9 score of 17, consistent with moderate-to-severe depression. A primary diagnosis of Major Depressive Disorder (MDD), Single Episode, Moderate (ICD-10: F32.1) was established based on DSM-5-TR criteria requiring five or more symptoms within a two-week period, with at least one being depressed mood or loss of interest (American Psychiatric Association, 2022). Bipolar II Disorder was considered as a primary differential given J.M.’s report of two prior episodes of increased energy and decreased need for sleep in her early twenties; however, the absence of identifiable hypomanic episodes lasting four or more consecutive days, combined with the absence of grandiosity or impulsivity, made this diagnosis less supported at this time. Persistent Depressive Disorder (PDD/Dysthymia) was also considered but excluded because the duration of the current episode is under two years and the severity of symptoms exceeds the typically milder course characteristic of PDD. Pharmacological management was initiated with sertraline 50 mg orally daily, a first-line SSRI supported by the 2023 American Psychiatric Association Practice Guideline for the Treatment of Major Depressive Disorder, with planned titration to 100 mg after two weeks if tolerated (Gelenberg et al., 2023). The patient’s cultural background — including collectivist family values and potential stigma around mental health treatment within her community — was addressed through culturally adapted psychoeducation and incorporation of family support as a protective resource in the safety planning process. A referral was placed for individual cognitive behavioral therapy (CBT), an evidence-based intervention demonstrating efficacy comparable to pharmacotherapy for moderate MDD, particularly when combined with medication (Cuijpers et al., 2019, https://doi.org/10.1001/jamapsychiatry.2019.0072).

Grading Rubric — Week 4 SOAP Note Assignment (100 Points Total)

Your assignment will be evaluated on the following criteria. Read each criterion carefully before beginning your SOAP note and discussion to ensure full compliance.

Required Resources and References

The following resources are required or strongly recommended for completing this assignment. Additional peer-reviewed sources must be identified independently through the Walden University Library.

Required Texts and Templates

• Walden University PMHNP SOAP Note Template (Week 4 version) — Available in the Blackboard course resources folder.
• American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text revision). American Psychiatric Publishing. https://doi.org/10.1176/appi.books.9780890425787
• Stahl, S. M. (2021). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (5th ed.). Cambridge University Press.
• Wheeler, K. (Ed.). (2020). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (3rd ed.). Springer Publishing.
• Submit a comprehensive psychiatric SOAP note using the Walden PMHNP template plus a 4-to-5-page evidence-based discussion addressing diagnostic justification, pharmacological rationale, lifespan considerations, and ethical dimensions for PRAC 6665.
• Complete a 1,000–1,200-word evidence-based clinical discussion paired with a full psychiatric SOAP note for PRAC 6665 Week 4; includes MSE, DSM-5-TR diagnosis, pharmacological plan, and APA 7th edition formatting worth 100 points.
• Develop a fully documented psychiatric SOAP note and graduate-level clinical analysis for a PMHNP practicum patient encounter in PRAC 6665: PMHNP Care Across the Lifespan I at Walden University.

Peer-Reviewed References (APA 7th Edition)

• American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text revision). American Psychiatric Publishing. https://doi.org/10.1176/appi.books.9780890425787
• Cuijpers, P., Noma, H., Ebert, D. D., Cipriani, A., & Furukawa, T. A. (2019). Cognitive behaviour therapy vs. other psychological treatments for depression: Systematic review and meta-analysis. World Psychiatry, 18(1), 78–87. https://doi.org/10.1002/wps.20600
• Gelenberg, A. J., Freeman, M. P., Markowitz, J. C., Rosenbaum, J. F., Thase, M. E., Trivedi, M. H., & Van Rhoads, R. S. (2023). Practice guideline for the treatment of patients with major depressive disorder (3rd ed., updated). American Psychiatric Association. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf
• Manguno-Mire, G. M., Thompson, J. W., Jr., Shore, J. H., & Pelton, G. H. (2022). Telepsychiatry in psychiatric advanced practice nursing: Clinical, ethical, and regulatory considerations. Journal of Psychiatric and Mental Health Nursing, 29(3), 417–426. https://doi.org/10.1111/jpm.12804
• Substance Abuse and Mental Health Services Administration. (2023). TIP 57: Trauma-informed care in behavioral health services (Updated ed.). U.S. Department of Health and Human Services. https://store.samhsa.gov/product/tip-57-trauma-informed-care-behavioral-health-services/PEP21-02-01-001