Assignment 2: 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.
• 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.
o All SOAP notes must be signed, and each page must be initialed by your Preceptor.
Note: Electronic signatures are not accepted.
o When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor.
o You must submit your SOAP note using SafeAssign.
Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.
• Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record.
• Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
• Ensure that you have the appropriate lighting and equipment to record the 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.
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 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.
Assessment: Discuss patient mental status examination results. What were the various diagnoses that you considered? Give at least three potential diagnosis, along with an explanation of why you chose each one. Create a list with them in the order of highest to lowest priority. What was the primary diagnosis, and what was the reason for it? Describe how your primary diagnosis corresponds with the diagnostic criteria established by the DSM-5 and how the patient’s symptoms support this alignment.
o Plan: Describe your treatment plan by utilizing evidence-based practice and clinical practice guidelines. Include a discussion on the psychopharmacologic medicines that you have chosen that have been approved by the FDA, and also include a discussion on alternative treatments that are available and supported by valid research. Each potential course of therapy must include an explanation of the reasons behind the choice, which must be supported by relevant research. What was your plan for following up and what were the parameters? As a result of this treatment session, what referrals or recommendations would you make to the patient?
o Plan: 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? Demonstrate your critical thinking.
o 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.
K.K is a 27 y/o AA female who came to ER via ambulance due to severe depression with attempt to overdose on pills, suicidal ideations, severe anxiety, racing thoughts, and mood swings marijuana/alcohol abuse, and difficulty sleeping at night. Patient was found unresponsive in the bathroom; there was a bottle of Pepcid 20 mg on the floor. Patient also consumed alcohol. During assessment, patient stated, “I feel depressed, anxious, I can’t sleep, I have thoughts of wanting to hurt myself, I am so stressed out because I have to take care of my two kids by myself. I had couple shots and I was about to take a bunch of pills in the bathroom but I passed out before I could take any of the pills.” Patient denies present and past homicidal ideations. Per ER report patient has past suicidal attempt once in her lifetime via cutting her wrists. Denies any past inpatient psychiatric hospitalizations, denies seeing ant therapist or psychiatrist outpatient and denies being prescribed any psychotropic medications. Patient denies any medical history and drug allergies. Patient denies family history of mental illness. She reports being single has 2 children, lives with parents and unemployed. Her UDS was positive for marijuana and alcohol abuse. HCG negative. Patient denies family history mental illness.
3 DIAGNOSIS (NOTE: USE DSM-5 TO WRITE ABOUT THE BELOW DIAGOSIS AND RELATE IT TO PATIENT’S PROBLEM BASED ON HER HISTORY.
• Bipolar disorder mixed episode
• Substance abuse
• Anxiety disorder