Psychiatric Soap Note Essay

This week you participate in the second of three clinical discussions called grand rounds. In one of these 3 weeks, you will be a presenter as well as help facilitate the online discussion; in the others you will be an active discussion participant. When it is your week to present, you will create a focused SOAP note and a short didactic (teaching) video presenting a real (but de-identified) complex patient case from your practicum experience.(Psychiatric Soap Note Essay Example)

You should have received an assignment from your Instructor letting you know which week of the course you are assigned to present. 

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 this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
• Select a child/adolescent patient from your clinical experience that presents with a significant concern. Create a focused SOAP note for this patient using the template in the Resources. All SOAP notes must be signed by your Preceptor. When you submit your SOAP note, you should include the complete SOAP note as a Word document and PDF/images of completed assignment signed by your Preceptor. You must submit your SOAP note using Turnitin.Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.(Psychiatric Soap Note Essay Example)
• Then, based on your SOAP note of this patient, develop a video case study presentation. Set aside time to practice what you will say beforehand and ensure that you have the appropriate lighting and equipment to record the presentation.
• Your presentation should include objectives for your audience, at least three possible discussion questions/prompts for your classmates to respond to, and at least five scholarly resources to support your diagnostic reasoning and treatment plan.

Video assignment for this week’s presenters:

Record yourself presenting the complex case study for your clinical patient. In your presentation:

• Dress professionally and present yourself in a professional manner.
• Display your photo ID at the start of the video when you introduce yourself.
• 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).
• State 3–4 objectives for the presentation that are targeted, clear, use appropriate verbs from Bloom’s taxonomy, and address what the audience will know or be able to do after viewing.
• 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.
• Pose three questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.(Psychiatric Soap Note Essay Example)
• 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?(Psychiatric Soap Note Essay Example)
  • 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-TR diagnostic criteria and is supported by the patient’s symptoms.
  • Plan: What was your plan for psychotherapy (include one health promotion activity and patient education)? 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.  Discuss an identified social determinate of health impacting this patient’s mental health status and provide your recommendation for a referral to assist this patient in meeting this identified need (students will need to conduct research on this topic both in the literature and for community resources).
  • 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.(Psychiatric Soap Note Essay Example)

A note on grading: 

• Presenters: Review the Grand Rounds Presenter Rubric attached to this discussion to ensure you meet the scoring criteria.
• Participants: Review the Grand Rounds Participant Rubric located on the following Week 7 Assignment 1 page to ensure you meet the scoring criteria. Note the Week 7 Assignment 1 page is for viewing the participant rubric only. Your response should be posted in the forum of this page.(Psychiatric Soap Note Essay Example)

WEEK 7 PRESENTERS:

BY DAY 3

Post your video and your focused SOAP note to the Grand Rounds Discussion forum. You must submit two files for the SOAP note, including a Word document and scanned PDF/images of completed assignment signed by your Preceptor. Then, actively respond to and guide the conversation as your colleagues post responses to your video.

WEEK 7 PARTICIPANTS:

BY MULTIPLE DAYS BETWEEN DAYS 4 AND 7

Respond at least 2 times each to all colleagues who presented this week (should be 2-3 presenters each week). The goal is for the discussion forum to function as robust clinical conferences on the patients. Provide a response to 1 of the 3 discussion prompts that your colleagues provided in their video presentations. You may also provide additional information, alternative points of view, research to support treatment, or patient education strategies you might use with the relevant patient.

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ReplyReply to Week 7: Discussion

Psychiatric Soap Note Essay Example

Subjective:

CC: “I dont think I will ever recover from the event and the humiliation that followed. Life is not fair, and I don’t think I can live longer as I wished.”(Psychiatric Soap Note Essay Example)

HPI: VL is an 18-year-old African American female present for psychiatric assessment and medication. VL has lived with her elder sister since her parents died ten years ago. The client says, “I have had a fairly good life, living with my sister. However, the events in the past few months have left me battered, and I think I will never recover from these memories.” The client reports feeling flat and doesn’t feel like going back to school again, but my sister says I need to. Despite my body size, I was a good student, and fellow students liked me, albeit not all. So basically, three of my classmates ganged and raped me in the classroom. I despise them for it. I would have killed them, you know, but my sister and the pastor talked to be against it. I have seen sense, but it still hurts. Everybody at school knows me, and whenever I pass, every eye stares at me, and I know what they are thinking. I am scared, sad, and afraid of all men I come across. I don’t feel like going outside to face people. They called me “poor fatty” at school because I am overweight and could resit them.” The client reports not going to school last three months since the media showed my face, and she is hurting because the police have not persecuted the boys. “I rarely sleep at night or lock my bedroom door to feel my sister’s presence with me. My sister says I have nightmares after which I recount the event vividly.” The client reports losing two pounds in the last month and doesn’t feel like not eating as I used to.”(Psychiatric Soap Note Essay Example)

Substance Current Use: The client denies using nicotine/tobacco products or ETOH. Reports drinking to be sober. No Blackouts, seizures, or hallucinations from drugs or alcohol.(Psychiatric Soap Note Essay Example)

Medical History:                                                                 

• Current Medications: Citalopram 20 mg PO qDay for depression.
• Allergies: Pollen(Psychiatric Soap Note Essay Example)
• Reproductive Hx: Normal menstruation, last month. Not pregnant. Uses birth control pills

Psychotherapy or previous psychiatric diagnosis: None Reported.

Current Medications: None reported. 

Medication trials: None reported. (Psychiatric Soap Note Essay Example)

Family psychiatric/substance use: None reported.

Social: Raised by the sister. Not married. Mother 10 years ago. She currently lives with her sister. Never known his dad. No legal issues. The client is in 12^th grade.

ROS:

GENERAL: 2-pound weight loss. No fever or chills.

HEENT: No headache. Normal vision and hearing. No breathing or swallowing difficulty.

SKIN: No rash or abrasions.(Psychiatric Soap Note Essay Example)

CARDIOVASCULAR: No orthopnea, edema, or chest pain.

RESPIRATORY: No cough or wheeze.(Psychiatric Soap Note Essay Example)

GASTROINTESTINAL: No abdominal pain.

GENITOURINARY: Regular menses. Not pregnant.

NEUROLOGICAL: No Blackouts, seizures, or hallucinations

MUSCULOSKELETAL: No visible joint swelling or pain.

HEMATOLOGIC: No report of easy bleeding.

LYMPHATICS: No enlarged nodes.(Psychiatric Soap Note Essay Example)

ENDOCRINOLOGIC: No hypothyroidism.

Objective:

Temp: 97 F, BP: 113/74, HR: 78, R: 16, O2: 97, Ht: 5’3’’, Wt: 180lbs, BMI: 26.2 kg/m²

Diagnostic results:

Lab findings: WNL

Tox screen: Positive for nicotine

Alcohol: Positive

PC-PTSD-5: 34

Assessment:

Mental Status Examination: VL is an 18-year-old African Americal female who looks slightly older than her age. The client is cooperative and conversant. The client is oriented ×4. VL is disoriented and appears to be in acute distress. Psychomotor activity is within normal limits. VL maintains appropriate eye contact. Affect is flat with a reported mood of sadness. Resigned thoughtform and content. Has concentration difficulties during the exam. The client is not delusional. The client reports suicide ideation and homicidal ideation in remission. The client’s speech is organized, expresses herself without difficulty, and average rate. No abnormal thought content was elicited. The thought process is linear and preoccupied. Average cognitive ability, attention span, and concentration. Normal ability to abstract thought with an average amount of knowledge. The client’s memory and judgment are grossly intact, recalling all medical, family, and social history.(Psychiatric Soap Note Essay Example)

Diagnostic Impression: VL’s medical history and psychiatric assessments point to Posttraumatic stress disorder (PTSD). The DSM-5 Code for PSTD is 309.81, ICD-10 is 43.10. The patient’s symptoms meet the DSM-5 diagnostic criteria for PSTD, including exposure to sexual violence, recurrent and intrusive memories associated with the traumatic event, dreams, and persistent avoidance of stressors related to the traumatic event. Suicidality, insomnia, nightmares, and sleep disturbances are hallmarks of PSTD (Weber, Norra, & Wetter (2020). Differential diagnoses include Acute Stress Disorder (ASD) and Major Depression Disorder (MDD). VL’s symptoms include direct exposure to a traumatic event, recurrent and intrusive depressing memories, negative mood, avoidance of traumatic memories, and sleep disturbance are characteristic of ASD. This diagnosis is refuted. Equally, MDD is refuted since the client does not present psychomotor agitation, fatigue, recurrent thoughts of death, or diminished pleasure in most activities.(Psychiatric Soap Note Essay Example)

Reflections: Psychiatric assessment is critical to providing a definitive diagnosis and guide treatment plan. Subjective and objective information support diagnosis and guide assessment trajectory (Abd El-Hay, 2018). Therefore, a comprehensive evaluation of a client’s medical history and symptoms provides a diagnosis foundation. The client can articulate his needs and is willing to comply with the proposed medication plan. The client is not a risk to herself or others and understands the need for intervention. The potential risks and benefits of treatment are reviewed.(Psychiatric Soap Note Essay Example)

Case Formulation and Treatment Plan: 

Stop Citalopram. Although approved for major depression disorder, Citalopram causes QT interval prolongation, increases weight loss, sleep disturbances, and diminished appetite (Shoar et al., 2021).

Start Sertraline. Sertraline is safe for use in treating youth diagnosed with PSTD, increases the response rate, and improves symptoms (Huang et al., 2020).(Psychiatric Soap Note Essay Example)

Start Prolonged Exposure (PE) therapy. The America Psychiatric Association therapy recommends. PE stresses a gradual approach to an individual’s traumatic memories, learning the cues and not avoiding them (Watkins, Sprang, & Rothbaum, 2018).  (Psychiatric Soap Note Essay Example)

Referred to a nutritionist and psychiatrist for further evaluation and recommendation. PTSD is associated with reduced healthy eating (van den Berk-Clark et al., 2018).

Supportive listening was provided, and question time was provided.

Return to the clinic: After two weeks.

References

Abd El-Hay, M. A. (2018). Essentials of Psychiatric Assessment. Routledge. http://dx.doi.org/10.4324/9781315148137

Association, American Psychiatric. (2013). Diagnostic and statistical manual of mental disorders. American Psychiatric Publishing.

Weber, F. C., Norra, C., & Wetter, T. C. (2020). Sleep disturbances and suicidality in posttraumatic stress disorder: an overview of the literature. Frontiers in psychiatry, 11, 167. https://doi.org/10.3389/fpsyt.2020.00167

van den Berk-Clark, C., Secrest, S., Walls, J., Hallberg, E., Lustman, P. J., Schneider, F. D., & Scherrer, J. F. (2018). Association between posttraumatic stress disorder and lack of exercise, poor diet, obesity, and co-occurring smoking: A systematic review and meta-analysis. Health Psychology, 37(5), 407. https://dx.doi.org/10.1037%2Fhea0000593

Watkins, L. E., Sprang, K. R., & Rothbaum, B. O. (2018). Treating PTSD: A review of evidence-based psychotherapy interventions. Frontiers in behavioral neuroscience, 12, 258. https://doi.org/10.3389/fnbeh.2018.00258

Shoar, N. S., Fariba, K. A., & Padhy, R. K. (2021). Citalopram. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482222/

Huang, Z. D., Zhao, Y. F., Li, S., Gu, H. Y., Lin, L. L., Yang, Z. Y.,  … & Luo, J. (2020). Comparative efficacy and acceptability of pharmaceutical management for adults with posttraumatic stress disorder: a systematic review and meta-analysis. Frontiers in pharmacology, 11, 559. https://doi.org/10.3389/fphar.2020.00559

Frequently Asked Questions

What is a SOAP note for a psychiatric patient?

A SOAP note for a psychiatric patient is a structured clinical documentation format used by healthcare professionals to record subjective observations, objective findings, assessments, and treatment plans related to the patient’s mental health condition. It serves as a concise and organized tool to track the patient’s progress, communicate between healthcare providers, and ensure comprehensive and effective care.(Psychiatric Soap Note Essay Example)

How do you write a SOAP note for psychiatry?

A SOAP note for psychiatry consists of four sections:

1. Subjective: Record the patient’s reported symptoms, feelings, and experiences.
2. Objective: Document observable and measurable information like vital signs, appearance, and behavior.
3. Assessment: Provide a clinical diagnosis and discuss the patient’s mental health status.
4. Plan: Outline the treatment approach, including medications, therapy, and follow-up, as well as any changes to the patient’s care.(Psychiatric Soap Note Essay Example)

What is Objective psychiatric SOAP note?

An objective psychiatric SOAP note is a concise and structured documentation used by mental health professionals to record a patient’s clinical information and progress. It includes objective observations, measurable data, and diagnostic assessments, forming a vital part of the patient’s medical record and treatment plan.(Psychiatric Soap Note Essay Example)

What are the 4 parts of SOAP?

SOAP (Simple Object Access Protocol) consists of four main parts:

1. Envelope: This defines the structure of the message and includes information about how to process the message.
2. Header: Contains optional metadata and application-specific information about the message.
3. Body: Contains the actual data being transmitted in the message.(Psychiatric Soap Note Essay Example)
4. Fault: Provides information about errors that might have occurred during the processing of the message.