PRAC 6665: PMHNP Care Across the Lifespan I
Subjective:
CC (chief complaint):
HPI:
Substance Current Use:
Medical History:
- Current Medications:
- Allergies:
- Reproductive Hx:
ROS:
- GENERAL:
- HEENT:
- SKIN:
- CARDIOVASCULAR:
- RESPIRATORY:
- GASTROINTESTINAL:
- GENITOURINARY:
- NEUROLOGICAL:
- MUSCULOSKELETAL:
- HEMATOLOGIC:
- LYMPHATICS:
- ENDOCRINOLOGIC:
Objective:
Diagnostic results:
Assessment:
Mental Status Examination:
Diagnostic Impression:
Reflections:
Case Formulation and Treatment Plan:
PRECEPTOR VERFICIATION:
I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.
Preceptor signature: ________________________________________________________
Date: ________________________
References
14-year-old Male with ADHD Focused SOAP Psychiatric Evaluation Template
Subjective
CC (Chief Complaint): Difficulty focusing and staying on task.
HPI (History of Present Illness): A 14-year-old male presents with ongoing difficulties in maintaining attention and concentration, particularly in school settings. His parents report that he often struggles to complete homework and is easily distracted. These symptoms have been present since early childhood but have become more pronounced over the past year.
Substance Current Use: Denies use of tobacco, alcohol, or illicit drugs.
Medical History
- Diagnosed with ADHD at age 8.
- No significant past medical history.
Current Medications:
- Methylphenidate (Ritalin) 20mg once daily.
Allergies:
- None known.
Reproductive Hx:
- Not applicable.
ROS (Review of Systems)
- GENERAL: Reports difficulty sleeping. No recent weight changes.
- HEENT: No headaches, vision, or hearing problems.
- SKIN: No rashes or itching.
- CARDIOVASCULAR: No chest pain or palpitations.
- RESPIRATORY: No cough or shortness of breath.
- GASTROINTESTINAL: No nausea, vomiting, or diarrhea.
- GENITOURINARY: No dysuria or hematuria.
- NEUROLOGICAL: Reports difficulty focusing. No seizures or loss of consciousness.
- MUSCULOSKELETAL: No joint pain or muscle weakness.
- HEMATOLOGIC: No bleeding or bruising.
- LYMPHATICS: No swollen lymph nodes.
- ENDOCRINOLOGIC: No polyuria or polydipsia.
Objective
Diagnostic Results
- Previous psychological evaluation confirming ADHD diagnosis.
- Recent teacher reports indicating consistent inattentiveness and distractibility.
Assessment
Mental Status Examination
- Appearance: Well-groomed, appropriate attire for age.
- Behavior: Cooperative but fidgety.
- Speech: Normal rate and tone.
- Mood: “Frustrated” (patient’s own words).
- Affect: Appropriate to context.
- Thought Process: Logical and goal-directed.
- Thought Content: No evidence of delusions or hallucinations.
- Cognition: Alert and oriented to time, place, and person.
- Insight: Limited insight into his attention difficulties.
- Judgment: Fair for his age.
Diagnostic Impression
- ADHD, Combined Presentation (F90.2).
Reflections
- The patient’s difficulties with attention and hyperactivity are consistent with his ADHD diagnosis. His current medication appears to provide some benefit but may require adjustment.
Case Formulation and Treatment Plan
- Medication: Consider a medication review and potential adjustment of methylphenidate dosage.
- Behavioral Therapy: Recommend behavioral therapy to develop coping strategies and improve focus.
- School Support: Coordination with school for academic accommodations and support.
- Follow-up: Schedule follow-up in 1 month to assess medication efficacy and review therapy progress.
This sample SOAP note provides a comprehensive overview of the patient’s current status and a structured plan for ongoing management.
Must Read: ADHD soap note example