Write an assessment and tentative treatment plan. You may use the Assessment and Plan sections from the PMHNP SOAP note template for this, or choose to write this out in a paragraph form.
E.L. is a 84 year-old-woman who lives in her own home with a full-time caregiver and attends a day program on weekdays. E.L. has a history of bipolar disorder and moderate dementia. At baseline she is cantankerous and opinionated. More recently her caregiver reports that behaviors are agitated and oppositional.
E.L. is refusing most cares, is paranoid that, when her caregiver is on the phone, she is talking about E.L. She has been resisting sleep, staying up late and waking in the middle of the night.
Her caregiver denies aggressive behaviors, but E.L. is arguing with other participants in her day program and is at risk of being kicked out of the program.
Current medications are depakote 1500 mg daily (last level was therapeutic), quetiapine 100 mg qhs, and bupropion 75 mg qd.
- Write an assessment and tentative treatment plan. You may use the Assessment and Plan sections from the PMHNP SOAP note template for this, or choose to write this out in a paragraph form. However, both the Assessment and Plan sections must be clearly identified and all components in these sections, as described in the PMHNP SOAP note template, must be included.
- Assessment — Identify preliminary diagnoses, supporting information, and target symptoms.
- Plan: Tentative treatment plan and rationale.
- Using at least 5 scholar citations and APA formatting, you must include references for your statements.