Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders

Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders

Subjective:

CC (chief complaint): “People are watching me and I hear voices that keep me up at night.”

HPI: Sherman Tremaine is a 57-year-old male presenting with several weeks of worsening paranoia and hallucinations. He reports that individuals are watching him through his window and believes the government is involved in monitoring him. He describes auditory hallucinations, including voices and loud music, which disrupt his sleep for days. He also reports visual disturbances, such as seeing shadows, and believes others are attempting to poison his food. His speech is disorganized with tangential and repetitive patterns. He denies suicidal or homicidal ideation. He has a history of psychiatric hospitalizations in early adulthood. He reports refusal of multiple antipsychotic medications due to past side effects, although he states Seroquel was somewhat tolerated. Symptoms are persistent and impairing his ability to function independently.

Substance Current Use:

Tobacco: Smokes approximately three packs per day

Alcohol: Drinks regularly, reports a 12-pack lasting one week

Marijuana: Past use, stopped three years ago

Denies cocaine or other illicit drug use

Medical History:

Type 2 diabetes mellitus

Reported history of fatty liver disease

• Current Medications: Metformin
• Allergies: No known drug allergies

• Reproductive Hx: Never married, No children, No reproductive concerns reported

 

ROS:

• GENERAL: Reports severe sleep disturbance for several days, fatigue present, denies fever or weight loss
  • HEENT: Denies headaches, vision changes, or hearing loss; endorses auditory hallucinations not based in reality
  • SKIN: Denies rashes, lesions, or skin changes
  • CARDIOVASCULAR: Denies chest pain, palpitations, or swelling
  • RESPIRATORY: Denies shortness of breath, cough, or wheezing
  • GASTROINTESTINAL: Denies nausea, vomiting, abdominal pain, or bowel changes
  • GENITOURINARY: Denies urinary frequency, urgency, or dysuria
  • NEUROLOGICAL: Denies seizures or loss of consciousness; reports altered perception and hallucinations
  • MUSCULOSKELETAL: Denies muscle pain, joint stiffness, or weakness
  • HEMATOLOGIC: Denies easy bruising or bleeding
  • LYMPHATICS: Denies lymph node enlargement
  • ENDOCRINOLOGIC: Reports diabetes; denies excessive thirst, urination, or temperature intolerance

Objective:

The patient appears disheveled with poor grooming noted on visual inspection. He is alert and awake during the encounter. No visible signs of acute physical distress are observed. The patient is able to sit and move without assistance, suggesting intact gross motor function. No abnormal movements such as tremors or rigidity are noted. Respirations appear even and unlabored based on visual observation. There are no visible skin lesions, wounds, or discoloration. Facial symmetry appears intact. Eye movements appear normal, although eye contact is inconsistent. No signs of intoxication, such as slurred speech or impaired coordination, are clearly observed. Assessment is limited to observable findings due to the nature of video evaluation.

Diagnostic results:

No current labs available

Assessment:

Mental Status Examination:

The patient is a 57-year-old male who appears disheveled with poor hygiene and grooming. He is alert but only partially oriented, as he shows uncertainty about the exact day. Behavior is guarded and suspicious, with frequent signs of internal preoccupation. Eye contact is inconsistent. Speech is disorganized, tangential, and repetitive, with occasional pressured quality. Mood is described as anxious, and affect is constricted. Thought process is loose and fragmented, with difficulty maintaining logical flow. Thought content is notable for paranoid delusions, including beliefs that people are watching him, following him, and attempting to poison his food. The patient endorses auditory hallucinations, including voices and music, as well as visual disturbances such as seeing shadows. He denies suicidal or homicidal ideation. Insight is poor, as he does not recognize his symptoms as pathological. Judgment is impaired, as evidenced by his inability to reality-test his beliefs and make appropriate decisions.

Diagnostic Impression:

Schizophrenia (ICD-10: F20.9)

Schizophrenia is the most likely diagnosis based on the patient’s presentation. The patient demonstrates multiple DSM-5-TR criteria, including persistent auditory hallucinations, paranoid delusions, and disorganized speech. He reports hearing voices and music that others do not hear, along with fixed beliefs that people are watching him and attempting to poison his food. His speech is tangential and difficult to follow, which reflects disorganized thought processes (Rantala et al., 2022). There is also clear functional impairment, as he is unemployed and socially isolated. Although the current episode is described as lasting several weeks, his history of prior psychiatric hospitalizations suggests a chronic course. Pertinent negatives include the absence of prominent mood episodes and no evidence that symptoms are caused by substances. These findings support schizophrenia over other psychotic disorders.

Schizoaffective Disorder (ICD-10: F25.9)

Schizoaffective disorder remains a differential diagnosis because the patient presents with significant psychotic symptoms, including hallucinations and delusions. According to DSM-5-TR criteria, this condition requires a major depressive or manic episode occurring concurrently with psychotic symptoms, along with at least two weeks of psychosis without mood symptoms (Pavlichenko et al., 2024). In this case, there is no clear evidence of a sustained mood episode. The patient does not report depressive symptoms such as persistent sadness or anhedonia, and there are no signs of mania such as elevated mood or decreased need for sleep unrelated to psychosis. The absence of mood symptoms is a key factor that argues against this diagnosis. Pertinent negatives include no documented mood instability and no history suggesting episodic mood disturbance tied to psychosis.

Substance/Medication-Induced Psychotic Disorder (ICD-10: F19.959)

Substance/medication-induced psychotic disorder is considered due to the patient’s history of alcohol use and past marijuana use. DSM-5-TR criteria require that psychotic symptoms develop during or soon after substance intoxication or withdrawal, and that the substance is capable of producing such symptoms (Bramness et al., 2024). Although the patient consumes alcohol regularly, there is no clear temporal relationship between substance use and the onset of psychosis. He denies current illicit drug use, and marijuana use stopped three years ago. Additionally, his symptoms appear persistent and not limited to periods of intoxication or withdrawal. Pertinent negatives include a lack of recent substance use associated with symptom onset and no evidence of fluctuating mental status related to intoxication. These factors make this diagnosis less likely compared to a primary psychotic disorder.

Reflections:

If the session were conducted again, I would improve my assessment by focusing more on the symptom timeline and functional decline. The patient provided vague responses about duration, so I would clarify the onset, progression, and triggers of symptoms. I would also assess medication history in more detail, including reasons for nonadherence and side effects, to guide better treatment planning. Greater attention would be placed on substance use patterns, especially alcohol intake, to rule out contributing factors. I would also assess cognitive status more thoroughly, including memory and attention. In addition, I would maintain clearer boundaries and structure during the interview to reduce tangential responses and improve the quality of collected data.

At follow-up, my next intervention would include coordinating care with primary care for management of diabetes and liver concerns, since medical comorbidities can affect psychiatric outcomes. I would also explore psychosocial interventions such as supported employment or structured day programs to improve functioning. Legal and ethical considerations include the duty to intervene if the patient repeatedly misuses emergency services, as he reports calling 911 due to delusions. I would also consider issues of self-neglect and need for protective services if functioning declines. Health promotion would focus on reducing alcohol intake and improving nutrition. Disease prevention would include screening for complications related to chronic illness and long-term medication use.

Case Formulation and Treatment Plan:

Psychotherapy:
The patient will be referred for supportive psychotherapy with a focus on building trust and improving engagement due to poor insight and paranoia. Cognitive behavioral therapy for psychosis will be introduced to help the patient examine delusional beliefs and reduce distress related to hallucinations. Therapy will also include reality testing and coping strategies for managing voices. Family involvement will be encouraged, especially with the sister, to support treatment adherence and monitor symptoms. The rationale is that structured therapy improves symptom control and reduces relapse in patients with chronic psychotic disorders.

Pharmacologic Treatment:
Initiate an atypical antipsychotic, such as quetiapine, since the patient reports prior tolerance. Start at a low dose and titrate gradually to reduce side effects and improve adherence. Consider long-acting injectable antipsychotics if nonadherence continues. Monitor metabolic parameters due to diabetes history. The rationale is that antipsychotics target dopamine dysregulation and reduce hallucinations and delusions.

Nonpharmacologic and Alternative Therapies:
Encourage sleep hygiene, structured daily routine, and reduction of alcohol and tobacco use. Consider peer support groups and community mental health services. Mindfulness and relaxation techniques may help reduce anxiety. The rationale is that lifestyle changes improve overall functioning and reduce symptom severity.

Health Promotion:
Promote smoking cessation due to heavy tobacco use and increased cardiovascular risk.

Patient Education:
Provide simple, clear education about the role of medication in reducing voices and improving sleep, using repetition due to impaired concentration.

Follow-Up:
Schedule follow-up within one week to assess medication response, side effects, and safety. Monitor for worsening psychosis, adherence, and need for higher level of care. Frequent follow-up is necessary due to the severity of symptoms and poor insight.

 

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Publishing. https://doi.org/10.1176/appi.books.9780890425787

Bramness, J. G., Hjorthøj, C., Niemelä, S., Taipale, H., & Rognli, E. B. (2024). Discussing the concept of substance-induced psychosis (SIP). Psychological Medicine, 54(11), 2852–2856. https://doi.org/10.1017/S0033291724001442

Pavlichenko, A., Petrova, N., & Stolyarov, A. (2024). The modern concept of schizoaffective disorder: a narrative review. Consortium Psychiatricum, 5(3), 42–55. https://doi.org/10.17816/CP15513

Rantala, M. J., Luoto, S., Borráz-León, J. I., & Krams, I. (2022). Schizophrenia: The new etiological synthesis. Neuroscience & Biobehavioral Reviews, 142, 104894. https://doi.org/10.1016/j.neubiorev.2022.104894

 

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Psychotic disorders change one’s sense of reality and cause abnormal thinking and perception. Patients presenting with psychotic disorders may suffer from delusions or hallucinations or may display negative symptoms such as lack of emotion or withdraw from social situations or relationships. Symptoms of medication-induced movement disorders can be mild or lethal and can include, for example, tremors, dystonic reactions, or serotonin syndrome.

For this Assignment, you will complete a focused SOAP note for a patient in a case study who has either a schizophrenia spectrum, other psychotic, or medication-induced movement disorder.

Resources

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

To Prepare

 

• 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: Sherman Tremaine . 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?
• 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, and list them 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.
• 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.
• 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 were able to 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.).
• 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).

By Day 7 of Week 5

Submit your Focused SOAP Note.

 

submission information

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Rubric

NRNP_6675_Week5_Assignment_Rubric

NRNP_6675_Week5_Assignment_Rubric
Criteria	Ratings	Pts
This criterion is linked to a Learning OutcomeCreate documentation in the Focused SOAP Note Template about your assigned patient.In the Subjective section, provide: • Chief complaint• History of present illness (HPI)• Past psychiatric history• Medication trials and current medications• Psychotherapy or previous psychiatric diagnosis• Pertinent substance use, family psychiatric/substance use, social, and medical history• Allergies• ROS	15 to >13.0 ptsExcellent 90%–100%The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. 13 to >11.0 ptsGood 80%–89%The response accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. 11 to >10.0 ptsFair 70%–79%The response describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis but is somewhat vague or contains minor innacuracies. 10 to >0 ptsPoor 0%–69%The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Or the subjective documentation is missing.	15 pts
This criterion is linked to a Learning OutcomeIn the Objective section, provide:• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses	15 to >13.0 ptsExcellent 90%–100%The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented. 13 to >11.0 ptsGood 80%–89%The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented. 11 to >10.0 ptsFair 70%–79%Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies. 10 to >0 ptsPoor 0%–69%The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed. Or the objective documentation is missing.	15 pts
This criterion is linked to a Learning OutcomeIn the Assessment section, provide:• Results of the mental status examination, presented in paragraph form• At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 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.	20 to >17.0 ptsExcellent 90%–100%The response thoroughly and accurately documents the results of the mental status exam…. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected. 17 to >15.0 ptsGood 80%–89%The response accurately documents the results of the mental status exam…. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the disorders selected. 15 to >13.0 ptsFair 70%–79%The response documents the results of the mental status exam with some vagueness or innacuracy…. Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vagueness or innacuracy. 13 to >0 ptsPoor 0%–69%The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or the assessment documentation is missing.	20 pts
This criterion is linked to a Learning OutcomeIn the Plan section, provide:• Your plan for psychotherapy• 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. • Incorporate one health promotion activity and one patient education strategy.	25 to >22.0 ptsExcellent 90%–100%The response provides an evidence-based, detailed, and appropriate plan for psychotherapy for the patient…. The response provides an evidence-based, detailed, and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A strong rationale for the plan is provided that demonstrates critical thinking and content understanding…. The response includes at least one evidence-based health promotion activity and one evidence-based patient education strategy. 22 to >19.0 ptsGood 80%–89%The response provides an evidence-based and appropriate plan for psychotherapy for the patient…. The response provides an evidence-based and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. An adequate rationale for the plan is provided…. The response includes at least one health promotion activity and one patient education strategy. 19 to >17.0 ptsFair 70%–79%The response provides a somewhat vague or inaccurate plan for psychotherapy for the patient…. The response provides a somewhat vague or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is weak or general…. The response includes one health promotion activity and one patient education strategy, but it may contain some vagueness or innacuracy. 17 to >0 ptsPoor 0%–69%The response provides an incomplete or inaccurate plan for psychotherapy for the patient…. The response provides an incomplete or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is inaccurate or missing…. The health promotion and patient education strategies are incomplete or missing.	25 pts
This criterion is linked to a Learning Outcome• Discussion include what may be done differently with this patient if student conducted the session again. Discussed the next intervention if you could follow up with this patient. The discussion was related to legal/ethical considerations (demonstrated critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention that take into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).	5 to >4.0 ptsExcellent 90%–100%Reflections are thorough, thoughtful, and demonstrate critical thinking. Reflections contain a discussion of all elements described within assignment directions. 4 to >3.5 ptsGood 80%–89%Reflections demonstrate critical thinking. Reflections contain 2 out of 3 (legal/ethical considerations, social determinate of health, health promotion) with consideration of patient factors and risk factors. 3.5 to >3.0 ptsFair 70%–79%Reflections are somewhat general or do not demonstrate critical thinking. Reflections contain 2 out of 3 (legal/ethical considerations, social determinate of health, health promotion) without consideration of patient factors and risk factors. 3 to >0 ptsPoor 0%–69%Reflections are incomplete, inaccurate, or missing.	5 pts
This criterion is linked to a Learning OutcomeProvide 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).	10 to >8.0 ptsExcellent 90%–100%The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making. 8 to >7.0 ptsGood 80%–89%The response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study. 7 to >6.0 ptsFair 70%–79%Three evidence-based resources are provided to support the assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification. 6 to >0 ptsPoor 0%–69%Two or fewer resources are provided to support the assessment and diagnosis decisions. The resources may not be current or evidence based.	10 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for parenthetical/in-text citations and reference list.	5 to >4.0 ptsExcellent 90%–100%Uses correct APA format with no errors 4 to >3.5 ptsGood 80%–89%Contains 1-2 APA format for parenthetical/in-text citations and reference list errors 3.5 to >3.0 ptsFair 70%–79%Contains 3-4 APA format for parenthetical/in-text citations and reference list errors 3 to >0 ptsPoor 0%–69%Contains five or more APA format for parenthetical/in-text citations and reference list errors	5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and punctuation	5 to >4.0 ptsExcellent 90%–100%Uses correct grammar, spelling, and punctuation with no errors 4 to >3.5 ptsGood 80%–89%Contains 1-2 grammar, spelling, and punctuation format errors 3.5 to >3.0 ptsFair 70%–79%Contains 3-4 grammar, spelling, and punctuation format errors 3 to >0 ptsPoor 0%–69%Contains five or more grammar, spelling, and punctuation format errors that interfere with the reader’s understanding	5 pts

Total Points: 100