Psychiatric Evaluation Soap Note Discussion Paper
Week (enter week #): (Focused SOAP Note on Depression) Student Name College of Nursing-PMHNP, Walden University NRNP 6635: Psychopathology and Diagnostic Reasoning Faculty Name Assignment Due Date NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template CC: “I want to kill myself, and I am going home to do my favorite thing.” HPI: N.R, a 61-year-old female, is presented by the police to the psychiatric department on suspicion of having suicidal thoughts per the Baker Act. The patient is completely unaware of why the police stopped her, claiming she was trying to go home in her automobile as she swerved to avoid speed bumps. Psychiatric Evaluation Soap Note Discussion Paper
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The patient is currently prescribed to Labetalol for her high blood pressure and metformin for controlling her blood sugar. The patient portrays rapid and loud speech and is tearful when speaking. The therapist, however, refers her for psychiatric assessment, and treatment. Past Psychiatric History: The patient reports a history of depression during the previous one to two years, citing difficulties at work, rising rent, and often staying in bed all day to the point of forgetting to take a shower and lacking the motivation to do anything. Upon examination, the caregivers noted that she had a depressed mood and portrayed symptoms such as manipulation and poor self-care, thus exhibiting a mental illness. There have been no medical trials reported in the past. Substance Current Use and History: Psychiatric Evaluation Soap Note Discussion Paper