29 Mar FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION.
Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you examined during the last 4 weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.
TO PREPARE
Select an adult patient that you examined during the last 4 weeks who presented with a disorder other than the disorder present in your Week 3 Case Presentation.
Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.
Please Note:
When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of the completed assignment signed by your Preceptor.
Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.
Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
THE ASSIGNMENT
Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide:
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 patient mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.
Plan: In your video, describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session?
In your written plan include all the above as well as include one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
Reflection notes: What would you do differently with this patient if you could conduct the session over? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.
THE PATIENT:
P. W. is a 25 y/o male who was seen for initial psychiatric evaluation admission. Pt is a software engineer. Has been working with a therapist for 6 months. for binge drinking and drug abuse-cocaine, and depression. Pt was arrested twice at age 16.
Pt denies triggers for binge drink, but report drinks daily from stress at work or when feeling down. Pt report started drinking at age 14 years old, and was getting it from his older brother. Pt have 1sibling, an older brother.
Pt currently lives with her girlfriend of 2 years who was concerned about how patient feels when he take drugs or drink alcohol.
Pt both parent alive, lives in Virginia Beach, and is in contact with them
Denies physical, sexual and mental abuse
Pt report straight A student when in school
Pt denies family history of mental health
Report maternal grandfather use to drink.
Pt reports last alcohol use 2 weeks ago, prior to that was month, but have not alcohol for a while.
Pt reports intrusive thought of hurting self, Suicidal ideation, but no plan or reason.
Pt reports on Lexapro 20mg, which was initially prescribed by PCP.
Pt arrested at 16 y/o for violating curfew
Pt said he has been in current job for 4 years now.
Pt said his future plans is to buy a house with his girlfriend in cheaper city.
Pt report he wants to stop alcohol completely
Ht: 5’ 10’, Wt: 180 lbs.
PHQ =9, GAD = 7
Patient to follow up in 2 weeks
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