Comprehensive SOAP NOTE Essay Examples on Psychotherapy

SOAP NOTE Essay Examples on Psychotherapy

Comprehensive SOAP NOTE Essay Examples on Psychotherapy

I want a SOAP note with 1 diagnosis plus 3 differential diagnoses, reflexion and conclusion.  

INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY

If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric 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. Below highlights by category are taken directly from the grading rubric for the assignment in Weeks 4–10. After reviewing the full details of the rubric, you can use it as a guide.(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

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.

•      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 diagnostic criteria for each differential diagnosis and explain what DSM-5 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.(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

•      Read rating descriptions to see the grading standards!

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!), 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.). (Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

(The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)  EXEMPLAR BEGINS HERE(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

Comprehensive SOAP NOTE Essay Examples on Psychotherapy

Comprehensive SOAP NOTE Essay Examples on Psychotherapy

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.(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

N.M. is a 34-year-old Asian male presents for psychiatric evaluation for anxiety. He is currently prescribed sertraline which he finds ineffective. His PCP referred him for evaluation and treatment.

Or

P.H., a 16-year-old Hispanic female, presents for psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her therapist for medication evaluation and treatment.(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

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.(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

Paint a picture of what is wrong with the patient. First what is bringing the patient to your evaluation.  Then, include a PSYCHIATRIC REVIEW OF SYMPTOMS.  The symptoms onset, duration, frequency, severity, and impact. Your description here will guide your differential diagnoses. 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.(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP. 

General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13.(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

Caregivers are listed if applicable.

Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors?(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it)

Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. Thirdly, you could document both.(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

Substance Use History: This section contains any 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.(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information. Be sure to include a reader’s key to your genogram or write up in narrative form.(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

Social History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology.  However, at a minimum, please include:(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

Where patient was born, who raised the patient

Number of brothers/sisters (what order is the patient within siblings)

Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children?

Educational Level

Hobbies:

Work History: currently working/profession, disabled, unemployed, retired?

Legal history: past hx, any current issues?

Trauma history: Any childhood or adult history of trauma?

Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical) 

Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries.

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(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

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!(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

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.(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

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.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

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

Physical exam (If applicable and if you have opportunity to perform—document if exam is completed by PCP): From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e., General: Head: EENT: etc.(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

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. (Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

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. (Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

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?(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), 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.).(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

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.(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

Subjective:

CC (chief complaint): “I want to cut my alcohol drinking habit.”

HPI: XX is a 31-year-old male who presented to the office and complained about alcohol addiction.  The patient reports excessive drinking as a teenager as he did not want to be bothered by anyone. “I think people did not love me, and I was always by myself. The patient reports being treated for alcohol, anxiety, and depression. The patient last took medication a month ago, including Neurontin 300 mg PO once a day, Prozac 40 mg, and Tegretol 200 mg in the morning and 200 mg at bedtime. The patient reported a history of suicide and once tried to drink himself to death. He went to a program for alcohol once a week. He went to UNDNJ for a few days due to a drinking problem in the ER and has been in the ER for alcohol several times. The patient wants to get back to medication. The patient denies a history of physical or sexual abuse.  The patient had his first drink at 16 years old. The patient’s goal is to get better and maintain a healthy lifestyle. (Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

Past Psychiatric History: Has a history of depression and anxiety.

General Statement: The patient reported that this is the first time he has sought help.  The patient denied seeking help as a teenager. The first time he sought help was a Rutgers in 2015, aged 25.

Caregivers: NA

Hospitalizations: The patient denied being ever hospitalized.

Medication trials: The patient denied any medical problems.

Psychotherapy or Previous Psychiatric Diagnosis: The patient is diagnosed with moderate Major Depressive Disorder (MDD), recurrent General Anxiety Disorder (GAD), and alcohol use disorder (AUD). (Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

Substance Use History:  The patient denied any other substance abuse

Family Psychiatric/Substance Use History: Father suffers from PTSD and anxiety, the mother has depression and anxiety, and the brother has depression, anxiety, and alcohol.(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

Social History: The patient was born and raised in Newark, NJ, by his mother. He is the oldest of four children. The patient started a relationship six months ago. 

Educational Level: He’s a high school graduate. 

Hobbies:  He’s been working for six months now.

Work History: He worked at McDonald’s, hotel, and car services, and now he’s working as a concierge.

Legal history: The patient denied any history of criminal activities.

Trauma history: Any childhood or adult history of trauma?

Violence Hx: No violent concern or safety issues.

Medical History: 

Current Medications: No current medications.

Allergies: None reported.

Reproductive Hx: NA

ROS:

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

HEENT: No headache. Eyes: No double vision. Ears: No hearing loss. Nose: No breathing difficulty. No nasal congestion. Throat: No sore throat.

SKIN: No skin rashes or itches.

CARDIOVASCULAR: No chest pain/pressure, edema, or palpitations.

RESPIRATORY: No difficulty with breath, wheeze, or cough.

GASTROINTESTINAL: No abdominal discomfort. 

GENITOURINARY: Not pregnant. No hematuria or dysurias.

NEUROLOGICAL:  No seizures, extreme tingling, or hallucinations. MUSCULOSKELETAL: No joint swelling, pain, or stiffness.

HEMATOLOGIC: No hemophilia.

LYMPHATICS: No enlarged nodes.

ENDOCRINOLOGIC: No hypothyroidism.

Objective:

Temp: 98 F, BP: 125/83, HR: 82, R: 18, O2: 97.8, Ht: 5’9’’, Wt: 160lbs, BMI: 23.6 kg/m2 

Diagnostic results:

Tox screen: Abnormal (Positive for alcohol)

Relevant Screening Tools:

  1. Columbia Suicide Severity Rating Scale (C-SSRS): A score of 3 indicates active suicide ideation. C-SSRS is effective for screening suicide risks (Salvi, 2019).(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)
  2. Patient Health Questionnaire (PHQ-9): A score of 19 indicates moderately severe depression. PHQ-9 is reliable for screening depression severity and suicide risks (Rossom et al., 2017; Sun et al., 2020)

Assessment:

Mental Status Examination: The patient is a 31-year-old male who looks his age. He is alert and oriented. He is well-kempt. He appears to be in acute distress. He is calm and interactive. His language is daily. He is upbeat with a broad and expansive emotional range. Thought form and content are future-oriented with a normal ability to abstract. The patient is cognitively intact.  His recent memories are intact. Has active suicide ideation. The patient is assessed to be at risk of self-harm.(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

Diagnostic Diagnosis: The patient’s symptoms meet the criteria for severe Alcohol Use Disorder (AUD), moderate Major Depressive Disorder (MDD), and recurrent Generalized Anxiety Disorder (GAD).

  1. Alcohol Use Disorder (AUD) – AUD is determined by characteristic alcohol use and a significant amount/period of alcohol abuse, extended time spent obtaining alcohol, craving for alcohol, or withdrawal over 12 months (American Psychiatric Association [APA], 2019). The patient reports starting alcohol aged 16, and at 31, he is still drinking. He also reports drinking excessively. He wants to cut down his drinking, but he is unable. Heavy and problematic alcohol use is considered a significant risk factor for alcohol use disorder in the USA (Kranzler & Soyka, 2018). The patient’s goal is to get better and maintain a healthy lifestyle free from alcohol abuse. Therefore, this is the primary diagnosis.(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)
  2. Avoidant Personality Disorder (AVPD)chronic feelings of social inadequacy characterize AVPD. The diagnostic features of APD include persistent social inhibition and hypersensitivity to negative judgments (APA, 2019). AVPD starts at an early age and has a lifelong impact on affected individuals (Lampe & Malhi, 2018). In this case, the patient did not want to be bothered by anyone as a teenager. He felt that nobody loved him and was always by himself, which could mean preoccupation with other people’s judgment. He did not seek help for his drinking problem and only sought help for the first time in 2015. However, the client does not report avoidance of occupational roles and unwillingness to get involved with others which are significant features of AVPD diagnosis. Besides, he reports starting a relationship six months ago. Therefore, this diagnosis is refuted.(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)
  3. Moderate Major Depressive Disorder (MDD) – The criteria for MDD diagnosis include depressed moor of pleasure presenting for two weeks. Insomnia, fatigue, weight loss, and recurrent suicide ideation are common with MDD (APA, 2019). The client reports being distant as a child, and this is the first time he is seeking help. Social isolation/loneliness is associated with depression in young people (Achterbergh et al., 2020). However, this diagnosis is refuted since the client does not report other significant MDD symptoms outlined in the DSM5.(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)
  4. Recurrent Generalized Anxiety Disorder (GAD) – GAD is characterized by anxiety and worries out of proportion on most days for six months or more. Difficulty controlling worry, restlessness, fatigue, difficulty concentrating, irritability, sleep disturbance, and muscle tension (APA, 2019). The patient is concerned with his drinking habit and potentially reaching a point of drinking himself to death and needs help. Individuals with GAD often feel on edge and helplessly tend to seek help for their anxiety (Munir et al., 2022). However, the patient does not present most of the GAD symptoms. Therefore, this diagnosis is refuted.(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

Reflections

I agree with the preceptor’s assessment and diagnostic impression of the patient. The client’s symptoms are characteristics of AUD, AVPD, MDD, and GAD. However, the patient’s symptoms are better explained by AUD as the primary diagnosis. The potential social determinant of health relevant to the client’s alcohol abuse is education level/literacy, healthy behaviors, social support, and coping skills. A lower education level is associated with higher alcohol consumption (Schmengler et al., 2022), which explains the client’s alcohol abuse as a teenager. Besides, a lack of social support and coping skills causes pathologic alcohol consumption (Moon et al., 2022). Lastly, factors such as advertisements and marketing of alcohol products and consequent ease of access in a person’s neighborhood can lead to alcohol abuse as a teenager and result in addiction in later life (Sudhinaraset et al., 2016). The patient’s goal is to get better and maintain a healthy lifestyle.(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

Conclusion

As a mental health care specialist, the patient should be advised on available community resources or alcohol for alcohol addiction, the need for social interactions, routine exercise, and suicide emergency care. Moreover, the patient needs to risks associated with AUD and the need for intervention.(Comprehensive SOAP NOTE Essay Examples on Psychotherapy)

References

Achterbergh, L., Pitman, A., Birken, M., Pearce, E., Sno, H., & Johnson, S. (2020). The experience of loneliness among young people with depression: a qualitative meta-synthesis of the literature. BMC Psychiatry20(1), 1-23. https://doi.org/10.1186/s12888-020-02818-3

American Psychiatric Association. (2019). Diagnostic and statistical manual of mental disorders (7th ed.). American Psychiatric Publishing, Inc.   

Kranzler, H. R., & Soyka, M. (2018). Diagnosis and pharmacotherapy of alcohol use disorder: a review. Jama320(8), 815-824. https://doi.org/10.1001%2Fjama.2018.11406

Munir, S., Takov, V., & Coletti, V. A. (2022). Generalized anxiety disorder (nursing). In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441870/

Rossom, R. C., Coleman, K. J., Ahmedani, B. K., Beck, A., Johnson, E., Oliver, M., & Simon, G. E. (2017). Suicidal ideation reported on the PHQ9 and the risk of suicidal behavior across age groups. Journal of Affective Disorders215, 77-84. https://doi.org/10.1016%2Fj.jad.2017.03.037

Salvi, J. (2019). Columbia-Suicide Severity Rating Scale (C-SSRS). Emergency Medicine Practice21(5), CD3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7974826/

Sun, Y., Fu, Z., Bo, Q., Mao, Z., Ma, X., & Wang, C. (2020). The reliability and validity of PHQ-9 in patients with major depressive disorder in psychiatric hospitals. BMC Psychiatry20(1), 1-7. https://doi.org/10.1186/s12888-020-02885-6

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