St Thomas University Nursing Video Script of Toddler Interview and Soap Note

Step 1:, students will create a video ( need help with the script ) presentation to perform a comprehensive psychiatric evaluation of a toddler. You will be graded on your interview skills when interviewing the persons performing as a toddler and a parent. You are expected to ask the patient and the parent questions the same way you do with your patients in the clinic.

Step 2: Each student will create a focused SOAP note. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive psychiatric SOAP note is to be written using the attached template below. Only the information asked in the video will be used for grading.

S =

Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS). Click here (Links to an external site.) for more details

O =

Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; and Mental Status Exam

A =

Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes

P =

Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up

Other:?Incorporate current clinical guidelines NIH Clinical Guidelines (Links to an external site.) or APA Clinical Guidelines (Links to an external site.), research articles, and the role of the PMHNP in your presentation.

Psychiatric Assessment of Infants and Toddlers (Links to an external site.)

Psychiatric Assessment of Children and Adolescents (Links to an external site.)

Reminder: It is important that you complete this assessment using your critical thinking skills. You are expected to synthesize your clinical assessment, formulate a psychiatric diagnosis, and develop a treatment plan independently. It is not acceptable to document “my preceptor made this diagnosis.” An example of the appropriate descriptors of the clinical evaluation is listed below. It is not acceptable to document “within normal limits.”

Graduate Mental Status Exam Guide Download Graduate Mental Status Exam Guide

Submission Instructions:

In addition to the video demonstrating proficiency in completing a comprehensive psychiatric evaluation, students must upload a comprehensive written submission.