Focused Soap Note and Patient Case Presentation Essay Paper

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Focused Soap Note and Patient Case Presentation Essay Paper

FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION

In your presentation:
• 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. Focused Soap Note and Patient Case Presentation Essay Paper
• 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:
o 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?
o Objective: What observations did you make during the psychiatric assessment?
o Assessment: Discuss their 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. Focused Soap Note and Patient Case Presentation Essay Paper
o 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?
o 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?  Focused Soap Note and Patient Case Presentation Essay Paper Demonstrate your critical thinking.
o Reflection notes: What would you do differently with this patient if you could conduct the session again? 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.

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Case study Focused Soap Note and Patient Case Presentation Essay Paper

Melanie Padgett is a 12-year-old girl who resides in Raleigh, NC. Her mother stated Melanie lost her father to a self-inflicted gunshot. Melanie was in the room next to where the incident occurred. The mother said Melanie loved her Dad and enjoyed spending time with him. Prior to the shooting incident, the mother explained how Melanie was doing very well at school and home. Lately, Melanie and her mother have moved from Raleigh, NC, to Florida, and they are back in Raleigh. The mother stated that Melanie has been feeling depressed, and now she’s beginning to show signs of missing her father. The mother said Melanie is sad at school from time to time, and she doesn’t talk much about the traumatic experience. The mother explained how Melanie really becomes depressed when events such as “Dad and Daughter dance” are given to her school. During these moments, Melanie really displays signs of missing her Dad. The mother stated that Melanie does well with her peers in school but spends most of her time playing with an IPAD when she’s at home. Melanie and her mother are staying with Melanie’s grandmother, which is uncomfortable for Melanie. The mother stated that Melanie is having a hard time processing suppressed emotions. The mother expressed how Melanie has been very sad and depressed since the shooting incident and the constant relocations. Focused Soap Note and Patient Case Presentation Essay Paper
She was recently in hospital for 6 days following making a declaration to some boys that she was going attempt suicide on Snapchat. She was started on Lexapro for depression. She has been missing her father, who killed himself about 2 years ago. She also has been feeling stressed about her grandmother and felt like they made her feel confused about being with her mother. She would not like to have contact with her mother’s family. She is still having nightmares about her father’s death and does not want to discuss it further.

NB: The following information is for you to use to complete the paper.

 

Family history: Mother has a history of Asthma, depression, and PTSD.
The Biological Mother Is the legal guardian.
Melanie has no medical issues or allergies. The patient don`t have history of substance use.
Vital signs : BP: 110/75, HR: 85, Resp: 20, O2: 97%, Temp: 97,6
All lab was within normal limits ( please mention them) Focused Soap Note and Patient Case Presentation Essay Paper
Mental Status
During her mental status examination, the patient is cooperative with the therapist. She is casually groomed and cleanly dressed appropriately. There is no evidence of any abnormal motor activity. Her speech is clear, coherent, and normal in volume and tone. Her thought process is goal-directed. There is evidence of a flight of ideas. She was in a depressed and anxious mood. Her affect was appropriate to her mood. She denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. She denies any current suicidal or homicidal ideation. Cognitively, she is alert and oriented. Her recent and remote memory is intact. Her concentration is good. Her insight is good.
Treatment Plan
Will continue Lexapro 10mg daily and start Vistaril 25 mg Bid for sleep and anxiety. Reviewed side adverse effects with the client and mother. The mother is agreeable to the regimen and will return in one month for follow-up. Focused Soap Note and Patient Case Presentation Essay Paper
The clinician recommends individual and family outpatient therapy. Family therapy would benefit the client’s recovery and achievement of her goals. Individual therapy using some CBT techniques might help the client recognize how her thoughts and feelings affect her behaviors.

The clinician recommends individual and family outpatient therapy. Family therapy is suggested because it would be beneficial to the client’s recovery and achieving her goals. Individual therapy using some CBT techniques might help the client recognize how her thoughts and feelings might affect her behaviors. Other CBT techniques will help the client to talk fluently about the traumatic event and process lingering emotions. The clinician believes that with family therapy, a clinical outcome could be good if the client is able to learn conflict management and how better to handle her feelings in relation to his family. Family therapy will also assist the client in establishing comfort in the family, and the help of family members will assist the client in getting through depressive episodes. Focused Soap Note and Patient Case Presentation Essay Paper

Differential diagnosis
F33.1 Major depressive disorder, recurrent, moderate
F43.12 Post-traumatic stress disorder, chronic
F41.9 Anxiety disorder, unspecified

NB: Please develop those 3 diagnoses using the DSM-5

Please Follow the Grading Criteria an

Comprehensive Focused SOAP Psychiatric Evaluation Template

Subjective:

CC (chief complaint): Depression, anxiety, nightmares related to father’s suicide Focused Soap Note and Patient Case Presentation Essay Paper

HPI: Two years ago, Melanie, a twelve-year-old girl witnessed her dad shoot himself to death. Since then she has been suffering from depression and anxiety and also has experienced sleep disorder with nightmares of traumatic event. Her state worsened after moving more than once and confronting difficulties linked to the family. After posting suicidal thoughts on social media, she was admitted to hospital for six days. Focused Soap Note and Patient Case Presentation Essay Paper

Substance Current Use: None

Medical History: No medical issues or allergies

Current Medications: Lexapro 10mg daily

Review of Systems (ROS):

General: Normal

HEENT: Normal

Skin: Normal

Cardiovascular: Normal

Respiratory: Normal

Gastrointestinal: Normal

Genitourinary: Normal

Neurological: Normal

Musculoskeletal: Normal

Hematologic: Normal

Lymphatics: Normal

Endocrinologic: Normal  Focused Soap Note and Patient Case Presentation Essay Paper

Objective:

Diagnostic results

Complete Blood Count (CBC): Normal

Comprehensive Metabolic Panel (CMP): Normal

Thyroid Function Tests (TFTs): Normal

Lipid Panel: Normal

Urinalysis: Normal

Electrolyte Panel: Normal

Liver Function Tests (LFTs): Normal

Blood Glucose: Normal

Assessment:

Mental Status Examination:

Melanie was cooperative at the time, dressed appropriately and casually groomed. No abnormal motor movements were observed to her. She spoke clearly, coherently, within normal volume and tone. Her thought process showed evidence of ideas in flight. She looked depressed and anxious. Her affect was congruent with depressed and anxious mood. There were no auditory or visual hallucinations reported, nor delusions noted in her thoughts. She denied having any suicidal or homicidal thoughts presently. She was alert and oriented with intact recent as well as remote memory cognitively. Concentration was good while insight remaining intact. Focused Soap Note and Patient Case Presentation Essay Paper

Diagnostic Impression:

F33.1 Major Depressive Disorder, Recurrent, Moderate

Melanie has core symptoms of Major Depressive Disorder, Recurrent, Moderate Severity according to DSM-5 criteria (Lye et al., 2020). Her low energy levels, loss of interest or pleasure in daily activities, insomnia or hypersomnia nearly every day, feelings of worthlessness or inappropriate guilt almost every day, diminished ability to think or concentrate and recurrent suicidal ideation are indicative of a major depressive episode that is moderately severe. In addition, these conditions make it difficult for her to have an active social life and perform well in school. Melanie exhibits the traits consistent with this diagnosis due to recurrence nature of her depression and current symptom presentation. Focused Soap Note and Patient Case Presentation Essay Paper

F43.12 Post-Traumatic Stress Disorder, Chronic

Melanie’ s experience of witnessing her father commit suicide is a traumatic event that has resulted in chronic Post-Traumatic Stress Disorder (Maercker et al., 2022). The traumatized child is re-experiencing the ordeal through intrusive thoughts, nightmares, and negative psychological states. She does not want to talk about the incident and this behavior may be accompanied by cognitive disruption such as sadness. The fight flight response can result in difficulties with sleep and increased anxiety levels. These issues have stayed for more than a month which negatively affect her daily activities and overall quality of life. Her condition matches the diagnostic criteria for chronic PTSD due to presence of disturbing symptoms over time. Focused Soap Note and Patient Case Presentation Essay Paper

F41.9 Anxiety Disorder, Unspecified

It is a fact that Melanie’s presentation meets the criteria for an Anxiety Disorder, Unspecified because of her excessive anxiety which she cannot control. She experiences restlessness as well as fatigue among other physical and cognitive symptoms of anxiety disorder (Rosellini & Brown, 2023). These symptoms impair her functioning in daily life and cause significant distress. Although her anxiety does not completely fit into the diagnostic criteria of certain other anxiety disorders like generalized anxiety disorder or specific phobia, its severity necessitates clinical attention and intervention. Focused Soap Note and Patient Case Presentation Essay Paper

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Reflections:

These diagnostic impressions make sense to me in relation to Melanie’s presentation and how it has affected her. The case shows that psychological consequences of traumatic experiences may be severe, especially among young people. For this reason, identification of mental disorders by carrying out screenings should not be underestimated. Focused Soap Note and Patient Case Presentation Essay Paper

According to Killackey et al. (2020), maintaining confidentiality or patients’ autonomy is a question of ethics as well as obtaining informed consent before commencing treatment and involving the mother in making decisions for a minor child, which is also known as legal guardian-ship. There are several socio-economic factors such as frequent relocations and unstable living situations that may exacerbate Melanie’s psychological state. It is important to consider her background and needs when providing culturally competent care. Focused Soap Note and Patient Case Presentation Essay Paper

Promotion of health can be done through teaching patients coping mechanisms, stress management techniques, and the importance of support systems among others. A patient should be educated about why they were treated with medication such as fluoxetine quetiapine or propranolol all used to treat post-traumatic stress disorder (PTSD) after an accident or illness. Focused Soap Note and Patient Case Presentation Essay Paper

Case Formulation and Treatment Plan:

  1. Continue with Lexapro 10mg every day for the treatment of Major Depressive Disorder (MDD). It is an SSRI antidepressant that can help alleviate depressive symptoms in children and adolescents where it is allowed by FDA (Yin et al., 2023).
  2. Begin Vistaril (hydroxyzine) 25mg twice a day to control her anxiety and sleeping problems. Anxiolytic, sedative antihistamine property and this can be used to manage the signs on Melanie’s case (Parish et al., 2023).
  3. Refer for individual psychotherapy, in particular Cognitive Behavioral Therapy (CBT). According to Friedl et al. (2020), this will enable Melanie identify and change thought and action patterns that are not helpful, which lead to anxiety as well as depression. Its trauma-focused CBT methods will help her process the traumatic event and emotions related to it. Focused Soap Note and Patient Case Presentation Essay Paper
  4. Recommend family therapy aimed at addressing family dynamics, improving communication skills, offering support for Melanie’s recuperation. The inclusion of families plays a significant role in creating positive environments that reinforce therapeutic approaches.
  5. Motivate kids and teenagers to join counseling sessions that will enable them recover from trauma or loss of a parent. Children participating in such group activities support each other in the sense that they create a feeling of belonging.
  6. Work together with Melanie’s school counselors to ensure that she gets special attention for her learning needs.
  7. Check up in four weeks’ time not just to see how far the treatment has responded, but also if there are side effects, which can then allow me make some changes on the plan as necessary. Provide contacts for crisis management in case of emergency situations. Focused Soap Note and Patient Case Presentation Essay Paper

Social Determinant of Health: Neighborhood and Built Environment (HealthyPeople 2030)

Melanie’s constant moving from one place to another and her being unable to have a stable home as she has been living with her grandmother may be responsible for the absence of a sense of community, limited availability of mental health services and escalation of stressors that interfere with her mental health.

Health Promotion Activity: To improve Melanie’s mood, reduce anxiety levels and enhance overall well-being, encourage involvement in sports or other age-appropriate activities that involve physical exercise. Focused Soap Note and Patient Case Presentation Essay Paper

Patient Education: Enlighten them about the physiological consequences of trauma, reasons for using medications or therapy as treatment approaches and significance of assuring supportive family atmosphere during healing process.

Reflections:

If I could organize this session again, I would focus more on Melanie’s mental health attributed by diverse aspects of life, including family dynamics and her living situation, that can have an enormous impact on her mental health. Furthermore, making the mother part of the treatment process will be important to create teamwork. Conducting the subsequent follow-up visit, I will perform evaluation of the efficacy of the adopted interventions while making corresponding changes if necessary dependent on Melanie’s reaction. Hence, constant surveillance accompanied by the relevant treatment plan are fundamental items of care in this case focusing on the complex requirements and fostering overall long-term recovery. Focused Soap Note and Patient Case Presentation Essay Paper

Grading Criteria

 

  1. Discuss Subjective data:• Chief complaint• History of present illness (HPI)• Medications• Psychotherapy or previous psychiatric diagnosis• Pertinent histories and/or ROS.

 

  1. This criterion is linked to a Learning OutcomeDiscuss Objective data:• 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. Focused Soap Note and Patient Case Presentation Essay Paper

 

  1. Discuss results of Assessment:• Results of the mental status examination• Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.

 

  1. Discuss treatment Plan:• A treatment plan for the patient that addresses chosen FDA-approved psychopharmacologic agents and includes alternative treatments available and supported by valid research. The treatment plan includes rationales, a plan for follow-up parameters, and referrals. The discussion includes one social determinant of health according to the HealthyPeople 2030, 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. Focused Soap Note and Patient Case Presentation Essay Paper

 

  1. Reflect on this case. Discuss what you learned and what you might do differently

INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY

If you are struggling with the format or remembering what to include, follow the Focused SOAP Note Evaluation Template AND the Rubric as your guide.  It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required.  After reviewing full details of the rubric, you can use it as a guide.

  1. Focused Soap Note and Patient Case Presentation Essay Paper

 

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

Read rating descriptions to see the grading standards! 

In 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. Focused Soap Note and Patient Case Presentation Essay Paper

Read rating descriptions to see the grading standards!

In 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-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.
  • Read rating descriptions to see the grading standards! 
  • Focused Soap Note and Patient Case Presentation Essay Paper

Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, 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.).

  1. Focused Soap Note and Patient Case Presentation Essay Paper

 

(The FOCUSED SOAP psychiatric evaluation is typically the follow-up visit patient note. You will practice writing this type of note in this course. You will be focusing more on the symptoms from your differential diagnosis from the comprehensive psychiatric evaluation narrowing to your diagnostic impression. You will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)

EXEMPLAR BEGINS HERE

Subjective:

CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member. Focused Soap Note and Patient Case Presentation Essay Paper

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:

N.M. is a 34-year-old Asian male presents for medication management follow up for anxiety. He was initiated sertraline last appt which he finds was effective for two weeks then symptoms began to return.

  1. Focused Soap Note and Patient Case Presentation Essay Paper

 

Or

P.H., a 16-year-old Hispanic female, presents for follow up to discuss previous psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications as we deferred until further testing and screening was conducted.

Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Focused Soap Note and Patient Case Presentation Essay Paper

Paint a picture of what is wrong with the patient. First what is bringing the patient to your follow up evaluation? Document symptom onset, duration, frequency, severity, and impact. What has worsened or improved since last appointment? What stressors are they facing? Your description here will guide your differential diagnoses into your diagnostic impression. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.

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history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures. Focused Soap Note and Patient Case Presentation Essay Paper

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse:  oral, anal, vaginal, other, any sexual concerns

ROS: Cover all body systems that may help you include or rule out a differential diagnosis.  Please note: THIS IS DIFFERENT from a physical examination! Focused Soap Note and Patient Case Presentation Essay Paper

You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema. Focused Soap Note and Patient Case Presentation Essay Paper

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising. Focused Soap Note and Patient Case Presentation Essay Paper

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Objective:

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines). Focused Soap Note and Patient Case Presentation Essay Paper

Assessment:

Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.  Focused Soap Note and Patient Case Presentation Essay Paper

He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking.   He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.  Focused Soap Note and Patient Case Presentation Essay Paper

Diagnostic Impression: You must begin to narrow your differential diagnosis to your diagnostic impression.  You must explain how and why (your rationale) you ruled out any of your differential diagnoses. You must explain how and why (your rationale) you concluded to your diagnostic impression.  You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case. Focused Soap Note and Patient Case Presentation Essay Paper

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), social determinates of health, 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.). Focused Soap Note and Patient Case Presentation Essay Paper

Case Formulation and Treatment Plan

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions including psychotherapy and/or psychopharmacology, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.  *See an example below. You will modify to your practice so there may be information excluded/included. If you are completing this for a practicum, what does your preceptor document? Focused Soap Note and Patient Case Presentation Essay Paper

Risks and benefits of medications are discussed including non- treatment. Potential side effects of medications discussed (be detailed in what side effects discussed). Informed client not to stop medication abruptly without discussing with providers. Instructed to call and report any adverse reactions. Discussed risk of medication with pregnancy/fetus, encouraged birth control, discussed if does become pregnant to inform provider as soon as possible. Discussed how some medications might decreased birth control pill, would need back up method (exclude for males).

 

Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. Discussed how drugs/alcohol affect mental health, physical health, sleep architecture. Focused Soap Note and Patient Case Presentation Essay Paper

 

Initiation of (list out any medication and why prescribed, any therapy services or referrals to specialist):

 

Client was encouraged to continue with case management and/or therapy services (if not provided by you)

 

Client has emergency numbers:  Emergency Services 911, the  Client’s Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)

 

Reviewed hospital records/therapist records for collaborative information; Reviewed PMP report (only if actually completed)

 

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (this relates to informed consent; you will need to assess their understanding and agreement) Focused Soap Note and Patient Case Presentation Essay Paper

 

Follow up with PCP as needed and/or for:

 

Labs ordered and/or reviewed (write out what diagnostic test ordered, rationale for ordering, and if discussed fasting/non fasting or other patient education)

 

Return to clinic:

Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care.

Focused Soap Note and Patient Case Presentation Essay Paper

References (move to begin on next page)

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting. Focused Soap Note and Patient Case Presentation Essay Paper