Each week students will choose one patient encounter to submit a Follow-up SOAP note for review.
Follow the rubric to develop your SOAP notes for this term.
The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.(ADHD SOAP Note Essay for Nursing Students)
Rubric
NU673 Unit 11 Assignment – Clinical: SOAP Note
NU673 Unit 11 Assignment – Clinical: SOAP Note
CriteriaRatingsPts
This criterion is linked to a Learning OutcomeSubjective Information
3 pts
Level 5
Complete and concise summary of pertinent information.
2 pts
Level 3
Well organized; partial but accurate summary of pertinent information (>80%).
1 pts
Level 1
Poorly organized and/or limited summary of pertinent information (50%-80%); information other than “S” provided.
0 pts
Level 0
Less than 50% of pertinent information is addressed; or is grossly incomplete and/or inaccurate.
3 pts
This criterion is linked to a Learning OutcomeObjective Information
3 pts
Level 5
Complete and concise summary of pertinent information.
2 pts
Level 3
Partial but accurate summary of pertinent information (>80%).
1 pts
Level 1
Poorly organized and/or limited summary of pertinent information (50%-80%); information other than “O” provided.
0 pts
Level 0
Less than 50% of pertinent information is addressed; or is grossly incomplete and/or inaccurate.
3 pts
This criterion is linked to a Learning OutcomeAssessment: Problem Identification and Prioritization
3 pts
Level 5
Complete problem list generated and rationally prioritized; no extraneous information or issues listed.
2 pts
Level 3
Most problems are identified and rationally prioritized, including the “main” problem for the case (>80%).
1 pts
Level 1
Some problems are identified (50%-80%); incomplete or inappropriate problem prioritization; includes nonexistent problems or extraneous information included.
0 pts
Level 0
Less than 50% of problems are listed; or main problem missed; or problems not prioritized and/or identified nonexistent problems.(ADHD SOAP Note Essay for Nursing Students)
3 pts
This criterion is linked to a Learning OutcomeAssessment: Assessment of Current Psychiatric & Medical Condition(s) or Drug Therapy-related Problem(ADHD SOAP Note Essay for Nursing Students)
3 pts
Level 5
An optimal and thorough assessment is present for each problem.
2 pts
Level 3
An assessment is present for each problem listed but not optimal.
1 pts
Level 1
Assessment is present for 50-80% of problems
0 pts
Level 0
Less than 50% of problems include an appropriate assessment.
3 pts
This criterion is linked to a Learning OutcomeAssessment: Treatment Goals
3 pts
Level 5
Appropriate and relevant therapeutic goals for each identified problem.
2 pts
Level 3
Appropriate therapeutic goals for most identified problems (>80%).
1 pts
Level 1
Appropriate therapeutic goals for a few identified problems (50%-80%).
0 pts
Level 0
Less than 50% of problems have appropriate therapeutic goals.
3 pts
This criterion is linked to a Learning OutcomePlan: Treatment Plan
3 pts
Level 5
Specific, appropriate and justified recommendations (including drug name, strength, route, frequency, and duration of therapy) for each identified problem.(ADHD SOAP Note Essay for Nursing Students)
2 pts
Level 3
Mostly complete and appropriate for each identified problem (>80%).
1 pts
Level 1
Partially complete and/or inappropriate for a few identified problems (50%-80%); information other than “P” provided.
0 pts
Level 0
Less than 50% of problems have an appropriate and complete treatment plan.
3 pts
This criterion is linked to a Learning OutcomePlan: Counseling, Referral, Monitoring & Follow-up
2 pts
Level 5
Specific patient education points, monitoring parameters, follow-up plan and (where applicable) referral plan for each identified problem.(ADHD SOAP Note Essay for Nursing Students)
1 pts
Level 3
Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for >80% of identified problems.
0.5 pts
Level 1
Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for a few identified problems (50%-80%).
0 pts
Level 0
Less than 50% of problems include appropriate counseling, monitoring, referral and/or follow-up plan.
ADHD SOAP Note Essay for Nursing Students
Criteria
Clinical Notes
Informed Consent
Patient’s ability and capacity to reply to the psychiatric interview questions is assumed(ADHD SOAP Note Essay for Nursing Students). The patient seems to be aware of the advantages and disadvantages of the psychiatric evaluation procedure and the anticipated psychotherapeutic/psychiatric therapies. He has given his verbal and written consent as an adult.(ADHD SOAP Note Essay for Nursing Students)
Subjective
Verify Patient Name: J.D. DOB: November 29th, 1992 Minor: X Accompanied by: N/A Demographic: 29-year-old male of Hispanic origin Gender Identifier Note: Male CC: ‘“My anxiety is worsening. I have anxiety, and lately I have struggled to concentrate on one activity. How can you help me with my anxiety?”’ HPI: 29-year-old male Mr. J.D. has a history of anxiety and ADHD. The patient claims that he has had ADHD since he was a youngster. His mother informed him that he was “all over the place, jumping off the wall” when he was younger, yet his disease was not identified until 2021. The patient said that he entered the institution in order to maintain his “sobriety,” that he is currently “trying to sort things out” on his own, and that he would like to take medicine to aid in his concentration(ADHD SOAP Note Essay for Nursing Students). The patient, who is a resident of a substance abuse treatment facility, claims that he is undergoing rehabilitation as a requirement to return to his mother’s home. Social Hx: Jimenez is a single, 29-year-old Hispanic man from the US. Since his parents were never wed, he spent his childhood and adolescence living with his mother(ADHD SOAP Note Essay for Nursing Students). Although he has just completed high school, the patient said he would like to complete his education by earning a college degree. Currently, he lives at a rehab facility for substance misuse(ADHD SOAP Note Essay for Nursing Students). His hobbies include fishing, reading, and talking to others. Legal Hx: The patient confessed to breaking into his friend’s home and stealing his mother’s marijuana at the age of 14. Despite being detained, he was not taken to jail(ADHD SOAP Note Essay for Nursing Students). Medical Hx: Denied Surgical Hx: Appendectomy in 2017 Psychiatric Hx: Patient has history of Anxiety and ADHD. Denied family history of mental illness. Psychiatric medication use: Adderall 30 mg daily, Xanax 1 mg daily, Clonidine 0.1 mg daily (at night). Substance Abuse history: Patient reported using multiple recreational drugs, for example: Marijuana, last used 3 weeks ago. Cocaine, last used a month ago Heroine, last used 5 years ago Xanax, last used 5 days ago (Xanax was not prescribed for patient, patient reported getting it from a friend). MSE: Mr. Jimenez was seen for psychiatric evaluation. The patient was dressed suitably for the situation and the season. He remained sitting the entire interview, was obedient, despite being very talkative, and showed no signs of discomfort. The patient denied experiencing paranoia, insomnia, loss of appetite, auditory or visual hallucinations, or suicidal or homicidal ideas. ROS:General: Denies weight loss, fever, chills, weakness, or fatigue. HEENT: Eyes: denies 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: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema. Respiratory(ADHD SOAP Note Essay for Nursing Students): Denies wheezes, shortness of breath, consistent coughs, and breathing difficulties while resting. Gastrointestinal: No anorexia, nausea, vomiting, or diarrhea(ADHD SOAP Note Essay for Nursing Students). No abdominal pain or blood. Genitourinary: Denies burning on urination, urgency, hesitancy, odor, odd color Neurological: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. Reports difficulties concentrating and paying attention. Musculoskeletal: Denies muscle, back pain, joint pain, or stiffness. Hematologic:(ADHD SOAP Note Essay for Nursing Students) Denies anemia, bleeding, or bruising. Lymphatics: Denies enlarged nodes. No history of splenectomy. Endocrinologic: Sweating, No reports of cold or heat intolerance. No polyuria or polydipsia. (ADHD SOAP Note Essay for Nursing Students)
Verify Patient: Name, Assigned identification number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo. Include demographics, chief complaint, subjective patient information, and the names and relations of others present in the interview.HPI:, Past Medical and Psychiatric History,Current Medications, Previous Psych Med trials,Allergies. Social History, Family History.Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…”
Objective
Vital Signs Temp: 98.3 F BP: 117/59 HR:71 R: 18; non-labored O2: 96% room air Pain: Negative Ht:5ft, 2 inches Wt.: 162 pounds. BMI:29.6 BMI Range: Overweight LABS: Lab findings WNL Tox screen: Negative Alcohol: Negative HCG: N/A Physical ExamGeneral appearance: The patient looks well-fed and in good health(ADHD SOAP Note Essay for Nursing Students). He converses and engages regularly with the medical staff, yet he quickly drifts away from the conversation or shifts the subject to something he is interested in. HEENT: Normocephalic and atraumatic. Sclera anicteric, No conjunctival erythema, PERRLA, oropharynx red, moist mucous membranes. Neck: Supple. No JVD. Trachea midline. No pain, swelling or palpable nodules. Heart/Peripheral Vascular: Regular rate and rhythm noted. No murmurs. No palpitation. No peripheral edema to palpation bilaterally. Cardiovascular: Although the patient’s heartbeat and rhythm are regular, there are murmurs and other sounds coming from his chest. The patient’s heart rate is constant and capillaries refill in two seconds. (ADHD SOAP Note Essay for Nursing Students) Musculoskeletal: Normal range of motion. Regular muscle mass for age. No signs of swelling or joint deformities. Respiratory: No wheezes and respirations are easy and regular. Neurological: Balance is stable, gait is normal, posture is erect, tone is good, and speech is clear. Psychiatric: (ADHD SOAP Note Essay for Nursing Students)The patient’s fast switching from one discussion or topic to another indicates inattentiveness. Patient is easily distracted, yet occasionally appears to pay attention to the caregiver. Neuropsychological testing: Patient has difficulties executing functions where he is required to prioritize, plan, inhibit behavior, and attend to processing speed. (ADHD SOAP Note Essay for Nursing Students)
This is where the “facts” are located.Vitals,**Physical Exam (if performed, will not be performed every visit in every setting)Include relevant labs, test results, MSE, risk assessment, and psychiatric screening measure results.
Assessment
DSM5 diagnosis: with ICD-10 codes F90.9. Attention-Deficit Hyperactivity Disorder (Confirmed): Millions of children are affected with attention-deficit/hyperactivity disorder (ADHD), a long-term mental health problem that often worsens as people get older. Hyperactivity, impulsive conduct, and problems maintaining attention are all persistent symptoms of ADHD(ADHD SOAP Note Essay for Nursing Students). Low self-esteem, problematic relationships, and poor involvement are common problems for people with ADHD, especially children (Magnus et al., 2017). Adult ADHD symptoms include impulsivity, disorganization, difficulty prioritizing, poor time management, difficulty focusing, difficulty multitasking, excessive activity and restlessness, poor planning, and a low threshold for irritation. The patient claimed feeling anxious and requesting medicine to aid with his concentration(ADHD SOAP Note Essay for Nursing Students). The DSM-5 diagnostic criteria for adults with ADHD include five or more inattentional symptoms, several of which must have been present before the age of 12, several of which must have been present in two settings, evidence that the symptoms interfere with or degrade social, academic, or occupational functioning, and symptoms that do not only occur in conjunction with another psychotic disorder (Magnus et al., 2017)(ADHD SOAP Note Essay for Nursing Students). The patient has a history of ADHD diagnosis and exhibits persistent loss of focus and attention. According to the evaluation, ADHD is the main diagnosis. F41.9. Generalized Anxiety Disorder: The hallmarks of generalized anxiety disorder (GAD) include excessive, exaggerated anxiety and worry over everyday events without any discernible cause (Munir et al., 2021). More than 6.8 million adults, or 3.1 percent of the population, are impacted. Although it can start at any point in the lifespan and manifest gradually, the risk is greatest between childhood and middle age. Although the specific etiology of GAD is unknown, biological factors, family history, life experiences, and other stressors all play a role (Toussaint et al., 2020)(ADHD SOAP Note Essay for Nursing Students). General anxiety disorder can be diagnosed by looking for signs such as excessive, persistent worry and tension, unrealistic views of problems, restlessness or a sense of being “edgy,” difficulty focusing, easily becoming exhausted, increased crankiness or irritability, trouble sleeping, and muscle tension. People with GAD often anticipate disaster and are overly concerned with normal day events like work. GAD is diagnosed when an individual cannot control worrying(ADHD SOAP Note Essay for Nursing Students). F19. 20. Psychotic Substance Dependence: Substance dependence is a condition characterized by abnormal brain activity brought on by the use of psychoactive substances that interfere with healthy emotional, motivational, and perceptual brain functions (de Matos et al., 2018). Alcohol, opioid, sedative or anxiolytic, cocaine, cannabis, and amphetamine dependence are examples of substance dependencies(ADHD SOAP Note Essay for Nursing Students). At least three of the following are necessary for a diagnosis of psychotic substance dependence: a substance frequently consumed in large doses over an extended period of time; a persistent desire to stop using it; one or more failed attempts to do so; a period of time required to obtain, use, or recover from its effects; frequent intoxication or withdrawal symptoms; giving up or reducing important social, occupational, or recreational activities in order to use substances; and continued use in spite of knowledge of the risks. After extended periods of time, the patient may acquire dependency syndrome. This diagnosis was refuted because the patient does not demonstrate drug dependence and abuse in large doses. (ADHD SOAP Note Essay for Nursing Students)
Include your findings, diagnosis, and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment.Informed Consent Ability
Plan (Note some items may only be applicable in the inpatient environment)
Pharmacologic interventions: Start Buspar 10 mg 1 tab PO BID.Venlafaxine 18.75-75 mg/day; may increase to 150 mg/day after 4 weeksBupropion Initial: 150 mg/day POImipramine 75 PO qDay initially(ADHD SOAP Note Essay for Nursing Students); may increase to 150 mg/day graduallyMetadate CD: Initial, 20 mg PO qAM before breakfastAtomoxetine 40 mg PO once daily initially; increase after ≥3 days to 80 mg PO once daily or divided q12hr PsychotherapyBehavioral psychotherapy: Enhancing executive function, reducing anxiety, and improving ADHD symptoms can all be achieved with the help of behavioral treatment and the right medication. Psychosocial interventions: (ADHD SOAP Note Essay for Nursing Students)ADHD and anxiety symptoms can be reduced with the help of psychosocial interventions such short-term psychodynamic psychotherapy, applied relaxation interpersonal psychotherapy, and social skills training. Cognitive therapy(ADHD SOAP Note Essay for Nursing Students): Cognitive-behavioral therapy helps reduce anxiety and restlessness sensations that arise when performing tasks, improve focus and time management, and improve mood (Lopez et al., 2018). Patient education Talk to the patient about risks and benefits of medication, including non-treatment, probable side effects.Discuss with patient when to stop medication, how to recognize and when to report adverse events.Talk to the patient about the dangers of combining prescription pharmaceuticals with OTC, illicit, or natural substances.Educate patient to develop structured daily routines, daily schedule, and minimize changes.Engage patient in skills training.Encourage patient to make time for exercise every day.Educate the patient to accept himself and his limitations and to interact with people that accept him.Teach patient to create a system for prioritizing the day and create deadlines for activities. Follow-up: Patient should follow-up after one week. Time spent in Psychotherapy 20 minutes The visit lasted 90 minutes Billing Codes for a visit: XX XX XX ____________________________________________ NAME, TITLE Date: Click here to enter a date. Time: X
References
de Matos, M. B., de Mola, C. L., Trettim, J. P., Jansen, K., da Silva, R. A., Souza, L., Ores, L., Molina, M. L., Coelho, F. T., Pinheiro, R. T., & Quevedo, L. A. (2018). Psychoactive substance abuse and dependence and its association with anxiety disorders: a population-based study of young adults in Brazil. Revista brasileira de psiquiatria (Sao Paulo, Brazil : 1999), 40(4), 349–353. https://doi.org/10.1590/1516-4446-2017-2258 Lopez, P. L., Torrente, F. M., Ciapponi, A., Lischinsky, A. G., Cetkovich-Bakmas, M., Rojas, J. I., Romano, M., & Manes, F. F. (2018). Cognitive-behavioural interventions for attention deficit hyperactivity disorder (ADHD) in adults. The Cochrane database of systematic reviews, 3(3), CD010840. https://doi.org/10.1002/14651858.CD010840.pub2 Magnus, W., Nazir, S., Anilkumar, A. C., & Shaban, K. (2017). Attention deficit hyperactivity disorder (ADHD). Munir, S., Takov, V., & Coletti, V. A. (2021). Generalized Anxiety Disorder (Nursing). StatPearls [Internet]. Toussaint, A., Hüsing, P., Gumz, A., Wingenfeld, K., Härter, M., Schramm, E., & Löwe, B. (2020). Sensitivity to change and minimal clinically important difference of the 7-item Generalized Anxiety Disorder Questionnaire (GAD-7). Journal of affective disorders, 265, 395-401.
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