-Select a patient of any age (either a child or an adult) that you examined during the last 3 weeks.

Jane,

I am going to post a SOAP note for a patient I met. Use that info to fill out a SOAP note template. With the info I give, you might not be able to answer all of the questions. You can just make up whatever you want. The SOAP note is purely psych, so if you want to put some medical stuff in you can. If not you do not have to. Just do your best. It is always good enough. If you see anything mentioned about a video presentation just ignore it. That is something I have to do on my own. Thanks!

My SOAP note

Subjective: Writer met with patient for individual session. 31-year-old female who is being treated for alcohol use disorder, also has a history of generalized anxiety disorder and depressive disorder. She experienced some racing thoughts, I had ordered her to begin low-dose olanzapine at bedtime to help with mood stability anxiety and sleep. Patient reports that she had a seizure this week but had not taken her olanzapine that day, she was evaluated Paoli Hospital, she did not suffer any consequences from the seizure, she is now “feeling a lot better” her anxiety has indeed improved, she started Antabuse and is expecting to begin Vivitrol soon. She is not reporting akathisia EPS or over-sedation.

Objective: Patient is casually dressed, well groomed, making good eye contact, her affect is superficially bright, she smiles and jokes appropriately, she is not psychomotor agitated, she is not lethargic, she is upbeat and hopeful for the future, her racing thoughts have seemed to decrease, she says she feels more “mellow” On the BuSpar, she is not reporting suicidal thoughts or hopelessness. She is still reporting some poor sleep, she says trazodone and Remeron did not agree with her in the past. She is alert and oriented x3 with fair insight and judgment. pt is highly motivated for recovery.

Assessment: Generalized anxiety disorder, depressive disorder, likely underlying bipolar 2 disorder, alcohol use disorder, severe, longstanding

Plan: Patient seems to like her BuSpar 15 mg twice a day, says it has been helpful, she is comfortable with current dose and does not want it changed. She is also comfortable with her low-dose olanzapine, there is no indication that it contributed to her seizure as she did not take it that day. She is still complaining of difficulty with sleep not helped by trazodone or Remeron. My suggestion instead is a trial of doxepin beginning 50 mg at bedtime, I reviewed potential risks with patient and she is agreeable. Will plan to follow up with her again in approximately 5 days, in the meantime she agrees to report any medication side effects or worsening mood or anxiety to nursing staff immediately in which case our service can be contacted to meet again more urgently if needed.

The Assignment

-Select a patient of any age (either a child or an adult) that you examined during the last 3 weeks.

-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. (I attached the SOAP note template and the exemplar)

-Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.

-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.

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 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.

Plan: What was your plan for psychotherapy? What was 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 be sure to include at least 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? 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.