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I will attach the link and the script/caption of the assigned video for assignment completion.  I will also attach the SOAP template to be used for the assignment as well as the example or exemplar of what the assignment should look like.  Please please please follow the example/exemplar attached.

 

In this Assignment, you use a case study to develop a focused SOAP note based on evidence-based approaches. 

 

• Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing anxiety, obsessive compulsive, and trauma-related disorders.
• Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
• Review the video, Case Study: Dev Cordoba. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
• Consider what history would be necessary to collect from this patient.
• Consider what interview questions you would need to ask this patient.

 

 

THE ASSIGNMENT:

Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:

 

• 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?
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• Objective: What observations did you make during the psychiatric assessment?
• Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest 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.
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• Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.
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• Reflection notes: What would you do differently with this patient if you could conduct the session again? Discuss what your next intervention would be if you could follow up with this patient. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), 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.).
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• Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).

 

 

References:

Walden University. (2021). Case study: Dev Cordoba. Walden University Canvas. https://waldenu.instructure.com 

 

• Centers for Disease Control and Prevention. (2020, April 3). Adverse childhood experiences (ACEs)Links to an external site.[Video]. https://www.cdc.gov/violenceprevention/aces/index.html
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• Dartmouth Films. (2018, September 25). Resilience Links to an external site.[Video]. YouTube.https://www.youtube.com/watch?v=bAXZVYDNURY
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• NCTSN. (2007). The promise of trauma-focused therapy for childhood sexual abuseLinks to an external site. [Video].https://www.nctsn.org/resources/promise-trauma-focused-therapy-childhood-sexual-abuse-video

• I will attach my study plan from last semester for reference.
•  
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• Revise your study plan summarizing your current strengths and opportunities for improvement.
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• Develop 3 new SMART goals for this quarter and the tasks you need to complete to accomplish each goal. Include a timetable for accomplishing them and a description of how you will measure your progress.
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• Describe resources you would use to accomplish your goals and tasks, such as ways to participate in a study group or review course, mnemonics and other mental strategies, and print or online resources you could use to study. You will submit 2 documents: the previous NRNP 6665 study plan and your NRNP 6675 revised study plan.

• I will attach case study template to be completed.
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• Assign DSM-5-TR diagnoses, ICD-10, and reimbursement codes to services based on the patient case scenario.
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Then, in 2-3 pages, address the following. You will add your narrative answers to these questions to the bottom of the case scenario document and submit them altogether as one document.

 

• What reimbursement billing code would you use for this session? Provide your justification for using this billing code.
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• Explain what pertinent information is required in documentation to support your chosen DSM-5-TR diagnoses, ICD-10 coding, and billing code.
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• Explain what pertinent documentation is missing from the case scenario and what other information would be helpful to narrow your coding and billing options. (There are at least 12 missing pertinent components of documentation).
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• Discuss legal and ethical dilemmas related to overbilling, upcoding, and fraudulent practices. Propose 2 strategies for promoting legal and ethical coding and billing practices within your future clinical roles.
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• Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.

I do not need a title page. I only need you to create the objectives and address the following based off of my attached SMART goals from previous assignment and enter these into the attached template. 

 

To Prepare

 

• Review your Clinical Skills Self-Assessment Form you submitted last week and think about areas for which you would like to gain application-level experience and/or continued growth as an advanced practice nurse. How can your experiences in the practicum help you achieve these aims?
• Review the information related to developing objectives provided in this week’s Learning Resources. Your practicum learning objectives that you want to achieve during your practicum experience must be:
  • Specific
  • Measurable
  • Attainable
  • Results-focused
  • Time-bound
  • Reflective of the higher-order domains of Bloom’s taxonomy (i.e., application level and above)
  •  

Note: Please make sure your objectives are individualized and outlined in your Practicum Experience Plan (PEP). While you may add previous objectives to continue to work toward. You must have 3 new objectives for each class, each quarter. 

 

• 1. Discuss your professional aims and your proposed practicum objectives with your Preceptor to ascertain if the necessary resources are available at your practicum site.
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• 2. Select one nursing theory and one counseling/psychotherapy theory to best guide your clinical practice. Explain why you selected these theories. Support your approach with evidence-based literature.
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• 3. Create a timeline of practicum activities that demonstrates how you plan to meet these goals and objectives based on your practicum requirements.
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The Assignment

 

Record the required information in each area of the Practicum Experience Plan template, including 3–4 measurable practicum learning objectives you will use to facilitate your learning during the practicum experience.  

For your final assignment, you’ll need to submit the final version of your paper, including the following components:

1. Title page 
2. Abstract
3. Complete Paper
4. References
5. Appendices
   1. Synthesis Table
   2. Evidence Table
   3. Make sure all these elements are polished and free of errors. Once everything is ready, upload the final document to your course platform by the deadline in either WORD DOC or PDF.

Make a single slide poster presentation using Panopto.

Ensure that your poster and presentation abide by the following guidelines:

• Your poster should be on a single PowerPoint slide and include a title, PICO and purpose statement, introduction/background, summary of the literature search, literature review, and practice recommendation.
• Your poster should be visually attractive, well organized with headers, and include appropriate spacing and graphics.
• Your presentation should be approximately 10 minutes in length and should include an introduction to the topic, the literature search process, literature review findings, and conclusion.

Introduction

In this final section, you will utilize your comprehensive understanding of the literature to articulate a practice recommendation. A practice recommendation requires an in-depth understanding of the literature surrounding the topic. One must take into account the quality, quantity, and consistency of the evidence found and appraised. 

Assignment Instructions

As appropriate to your paper, craft a narrative summary that includes a discussion of the following areas. This should be an integrated discussion. Do not write a paragraph for each of these areas.

Final Literature Summation and Recommendation:

• Begin with a succinct summation of the key findings from your literature review.
• Clearly define your evidence-based recommendation. This could be a new practice intervention, a confirmation of current practices, or a recommendation against change if the evidence does not support it.

Strength of the Recommendation:

• Discuss the strength of your recommendation, considering the evidence’s robustness. Is the recommendation strong based on substantial evidence, or is it tentative pending further research?

Quality of Evidence:

• Summarize the levels of evidence you have encountered. How does the quality of the evidence impact the certainty of your recommendation?

Balance of Benefit and Harm, Cost, and Feasibility:

• Critically analyze and discuss the balance between potential benefits and harms of implementing your recommendation.
• Consider the costs associated with your recommendation and its feasibility in practice settings.

Implications for Mental Health NP Practice:

• Reflect on how your recommendation fits into the broader context of Mental Health Nurse Practitioner practice. What are the implications for patient care, PMHNP responsibilities, and the healthcare system?

Future Interventions:

• Identify any potential interventions that emerged during your review that warrant further exploration. What avenues for future research or practice improvements did your literature review reveal?

Introduction

In this final section, you will utilize your comprehensive understanding of the literature to articulate a practice recommendation. A practice recommendation requires an in-depth understanding of the literature surrounding the topic. One must take into account the quality, quantity, and consistency of the evidence found and appraised. 

Assignment Instructions

As appropriate to your paper, craft a narrative summary that includes a discussion of the following areas. This should be an integrated discussion. Do not write a paragraph for each of these areas.

Final Literature Summation and Recommendation:

• Begin with a succinct summation of the key findings from your literature review.
• Clearly define your evidence-based recommendation. This could be a new practice intervention, a confirmation of current practices, or a recommendation against change if the evidence does not support it.

Strength of the Recommendation:

• Discuss the strength of your recommendation, considering the evidence’s robustness. Is the recommendation strong based on substantial evidence, or is it tentative pending further research?

Quality of Evidence:

• Summarize the levels of evidence you have encountered. How does the quality of the evidence impact the certainty of your recommendation?

Balance of Benefit and Harm, Cost, and Feasibility:

• Critically analyze and discuss the balance between potential benefits and harms of implementing your recommendation.
• Consider the costs associated with your recommendation and its feasibility in practice settings.

Implications for Mental Health NP Practice:

• Reflect on how your recommendation fits into the broader context of Mental Health Nurse Practitioner practice. What are the implications for patient care, PMHNP responsibilities, and the healthcare system?

Future Interventions:

• Identify any potential interventions that emerged during your review that warrant further exploration. What avenues for future research or practice improvements did your literature review reveal?

I will attach my previous assignment. This is for a Psychiatric and Mental Health Clinical with a PMHNP. Patients ranged in age from 5 years old to 89 years old. Feel free to elaborate and make up patients for assignment’s sake.

 

Journal Entry (450–500 words)

Learning From Experiences

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  • Revisit the goals and objectives from your Practicum Experience Plan. Explain the degree to which you achieved each during the practicum experience.
  • 1. Reflect on the three (3) most challenging patients you encountered during the practicum experience. What was most challenging about each?
  • 2. What did you learn from this experience?
  • 3. What resources were available?
  • 4. What evidence-based practice did you use for the patients?
  • 5. What would you do differently?
  • 6. How are you managing patient flow and volume?
  • 7. How can you apply your growing skillset to be a social change agent within your community?
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Communicating and Feedback

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  • Reflect on how you might improve your skills and knowledge, and communicate those efforts to your Preceptor.
  •  
  • Answer the questions: 
  • 1. How am I doing? 
  • 2. What is missing?
  • 3. Reflect on the formal and informal feedback you received from your Preceptor.

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• Write a 2-3 page paper: 
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• 1) Explain the controversy that surrounds dissociative disorders.
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• 2.) Explain your professional beliefs about dissociative disorders, supporting your rationale with at least three scholarly references from the literature.
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• 3.) Explain strategies for maintaining the therapeutic relationship with a client that may present with a dissociative disorder.
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• 4.) Finally, explain ethical and legal considerations related to dissociative disorders that you need to bring to your practice and why they are important.

 

Must have 3 scholarly references from the literature.