Depression SOAP Note Essay
The patient is a 46-year-old Hispanic Male who came into the office due to feeling depression. His chief complaint is “I am feeling depressed, and I am having suicidal thoughts, my love my family, and God causes me to seek help” He did plan to put his car on the railroad where he can be killed by a train. The patient has strong religious beliefs. He’s been praying.(Depression SOAP Note Essay Example)
The patient holds 2 degrees from NJIT. A BS and a master’s degree in electrical engineering from the New Jersey Institute of Technology. The patient has been working at his job for 20 years. He just got a promotion to a high degree. The new team he’s now working with is putting him down and making him feel stupid. He’s the only one in his department with a master’s degree. He’s bilingual. He speaks and writes English like a native. He is Hispanic. He’s been married for 22 years. He has 3 kids: ages 20, 16, and 12. He’s catholic. He’s happily married. He has his own house. He’s the first one in his family to graduate from college. The patient has a history of high cholesterol and type 2 diabetes. His vital sign is as follow: BP 134/82, pulse 82, temp 98.1 F, and respiration 16. 5’6 and 236 lb. He’s diagnosed with Major depression. He’s been experiencing, poor sleep, poor appetite, and poor concentration, Anxiety, lost interest in everything he used to enjoy. His medication is as Follows: Lexapro 10 mg PO daily, Metformin 1000 mg PO bid, Folic acid, vitamin d, Glipizide 4 mg bid and Zocor 10 mg PO QHS, Hydroxyzine 25 mg PO QHS prn for anxiety. No prior history of mental illness. No history of hospitalization. His urine drug screen is negative for everything. He’s the middle child. His mother and father are still alive. No family history of substance abuse or mental illness.(Depression SOAP Note Essay Example)
The patient is diagnosed with Major depression today. The patient signed a self-harm safety plan in the office. He denied SI/HI while he is in the office with his wife who is very supportive.
The patient is put on Lexapro 10 mg PO daily and psychotherapy twice a week. The patient’s medication is to be reviewed in 2 weeks.
PRAC_6665_Week7_Assignment2_Pt1_Rubric
PRAC_6665_Week7_Assignment2_Pt1_Rubric
CriteriaRatingsPts
This criterion is linked to a Learning OutcomePhoto ID display and professional attire
5 to >0.0 pts
Excellent
Photo ID is displayed. The student is dressed professionally.
0 pts
Fair
0 pts
Good
0 pts
Poor
Photo ID is not displayed. Student must remedy this before grade is posted. The student is not dressed professionally.
5 pts
This criterion is linked to a Learning OutcomeTime
5 to >0.0 pts
Excellent
The video does not exceed the 8-minute time limit.
0 pts
Fair
0 pts
Good
0 pts
Poor
The video exceeds the 8-minute time limit. (Note: Information presented after 8 minutes will not be evaluated for grade inclusion.)
5 pts
This criterion is linked to a Learning OutcomeDiscuss Subjective data:• Chief complaint• History of present illness (HPI)• Medications• Psychotherapy or previous psychiatric diagnosis• Pertinent histories and/or ROS(Depression SOAP Note Essay Example)
10 to >8.0 pts
Excellent
The video accurately and concisely presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis.(Depression SOAP Note Essay Example)
8 to >7.0 pts
Good
The video accurately presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis.
7 to >6.0 pts
Fair
The video presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis, but is somewhat vague or contains minor inaccuracies.(Depression SOAP Note Essay Example)
6 to >0 pts
Poor
The video presents an incomplete, inaccurate, or unnecessarily detailed/verbose description of the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis. Or subjective documentation is missing.
10 pts
This criterion is linked to a Learning OutcomeDiscuss Objective data:• 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(Depression SOAP Note Essay Example)
10 to >8.0 pts
Excellent
The video accurately and concisely documents the patient’s physical exam for pertinent systems. Pertinent diagnostic tests and their results are documented, as applicable.
8 to >7.0 pts
Good
The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are documented, as applicable.
7 to >6.0 pts
Fair
Documentation of the patient’s physical exam is somewhat vague or contains minor inaccuracies. Diagnostic tests and their results are documented but contain inaccuracies.
6 to >0 pts
Poor
The response provides incomplete, inaccurate, or unnecessarily detailed/verbose documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or objective documentation is missing.
10 pts
This criterion is linked to a Learning OutcomeDiscuss results of Assessment:• Results of the mental status examination• Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.(Depression SOAP Note Essay Example)
20 to >17.0 pts
Excellent
The video accurately documents the results of the mental status exam. Video presents at least three differentials in order of priority for a differential diagnosis of the patient, and a rationale for their selection. Response justifies the primary diagnosis and how it aligns with DSM-5 criteria.(Depression SOAP Note Essay Example)
17 to >15.0 pts
Good
The video adequately documents the results of the mental status exam. Video presents three differentials for the patient and a rationale for their selection. Response adequately justifies the primary diagnosis and how it aligns with DSM-5 criteria.
15 to >13.0 pts
Fair
The video presents the results of the mental status exam, with some vagueness or inaccuracy. Video presents three differentials for the patient and a rationale for their selection. Response somewhat vaguely justifies the primary diagnosis and how it aligns with DSM-5 criteria.(Depression SOAP Note Essay Example)
13 to >0 pts
Poor
The response provides an incomplete, inaccurate, or unnecessarily detailed/verbose description of the results of the mental status exam and explanation of the differential diagnoses. Or assessment documentation is missing.(Depression SOAP Note Essay Example)
20 pts
This criterion is linked to a Learning OutcomeDiscuss treatment Plan:• A treatment plan for the patient that addresses chosen FDA-approved psychopharmacologic agents and includes alternative treatments available and supported by valid research. The treatment plan includes rationales, a plan for follow-up parameters, and referrals. The discussion includes one social determinant of health according to the HealthyPeople 2030, 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.
20 to >17.0 pts
Excellent
The video clearly and concisely outlines an evidence-based treatment plan for the patient that addresses FDA-approved psychopharmacologic agents and includes alternative treatments and rationale supported by valid research. … Discussion includes a clear and concise follow-up plan and parameters…. The discussion includes a clear and concise referral plan. … The paper discussion contains all 3 elements from the assignment directions including a discussion demonstrating critical thinking of the case related to the HealthyPeople 2030 social health determinates. Clearly and concisely relates discussion to the psychiatric and mental health field.(Depression SOAP Note Essay Example)
17 to >15.0 pts
Good
The video clearly outlines an appropriate treatment plan without evidence-based discussion for the patient that addresses FDA-approved psychopharmacologic agents and includes alternative treatments and rationale supported by vague or questionable research. … Discussion includes a clear follow-up plan and parameters…. The discussion includes a clear referral plan…. The paper discussion contains 2 of the elements from the assignment directions with one being a basic discussion of the case related to the HealthyPeople 2030 social health determinates. Clearly relates discussion to the psychiatric and mental health field.(Depression SOAP Note Essay Example)
15 to >13.0 pts
Fair
The response somewhat vaguely or inaccurately outlines a treatment plan for the patient that addresses psychopharmacologic agents without discussion of FDA approval and includes vague or inaccurate alternative treatments with little rationale discussed. … The discussion is somewhat vague or inaccurate regarding the follow-up plan and parameters…. The discussion is somewhat vague or inaccurate regarding a referral plan. … The paper discussion contains 1 of the required elements from the assignment directions which is the HealthyPeople 2030 social health determinates…. Somewhat vaguely or inaccurately relates discussion to the psychiatric and mental health field.(Depression SOAP Note Essay Example)
13 to >0 pts
Poor
The response does not address the treatment plan or the treatment plan is not appropriate for the assessment and the diagnosis. There is no mention of FDA approval for treatment choices or no research supported discussion. Alternative treatment discussion is missing. … Rationales for treatments are missing. … There is no discussion for follow-up and parameters. … There is no discussion of a referral plan. … The paper discussion is missing discussion relating to the psychiatric and mental health field or relates discussion to another specialty realm including medical co-morbidity illnesses.(Depression SOAP Note Essay Example)
20 pts
This criterion is linked to a Learning OutcomeReflect on this case. Discuss what you learned and what you might do differently.
5 to >4.0 pts
Excellent
Reflections are thorough, thoughtful, and demonstrate critical thinking.
4 to >3.5 pts
Good
Reflections demonstrate critical thinking.
3.5 to >3.0 pts
Fair
Reflections are somewhat general or do not demonstrate critical thinking.
3 to >0 pts
Poor
Reflections are incomplete, inaccurate, or missing.
5 pts
This criterion is linked to a Learning OutcomePresentation style
5 to >4.0 pts
Excellent
Presentation style is exceptionally clear, professional, and focused.
4 to >3.5 pts
Good
Presentation style is clear, professional, and focused.
3.5 to >3.0 pts
Fair
Presentation style is mostly clear, professional, and focused
3 to >0 pts
Poor
Presentation style is unclear, unprofessional, and/or unfocused.
5 pts
Total Points: 80
Depression SOAP Note Essay Example
Subjective:
CC (chief complaint): “I am feeling depressed and having suicidal thoughts. My love for family and God caused me to seek help.”
HPI: The patient is a 46-year-old Hispanic male who presented to the office due to depression and suicidal thoughts. He reported that his love for his family and God led him to seek help. The patient planned to put his car on the railroad to be killed by a train. He reported strong religious beliefs and has been praying regularly. He has been experiencing poor sleep, appetite, concentration, anxiety, and loss of interest in activities he previously enjoyed. He reports that his new team at work is putting him down and making him feel stupid.(Depression SOAP Note Essay Example)
Substance Current Use: Denies drug and substance abuse.
Medical History: The patient has a history of high cholesterol and type 2 diabetes.
Current Medications: Lexapro 10 mg PO daily, Metformin 1000 mg PO BID, Folic acid, vitamin D, Glipizide 4 mg BID, Zocor 10 mg PO QHS, Hydroxyzine 25 mg PO QHS prn for anxiety.(Depression SOAP Note Essay Example)
Allergies: None known
Reproductive Hx: Not applicable
ROS:
- GENERAL: The patient reports feeling fatigued and having difficulty sleeping.
- HEENT: No headache. No sight or hearing complications.
- SKIN: No rashes or lesions.(Depression SOAP Note Essay Example)
- CARDIOVASCULAR: BP 134/82, pulse 82.
- RESPIRATORY: Respiration rate of 16.
- GASTROINTESTINAL: Poor appetite, no nausea or vomiting.
- GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color
- NEUROLOGICAL: Poor concentration.
- MUSCULOSKELETAL: No joint pain.(Depression SOAP Note Essay Example)
- HEMATOLOGIC: No history of bleeding disorders.
- LYMPHATICS: No history of lymphadenopathy.
- ENDOCRINOLOGIC: History of high cholesterol and type 2 diabetes.
Objective:
Diagnostic results: The patient’s urine drug screen was negative for all substances.
Assessment:
Mental Status Examination: He appears appropriately groomed and dressed. The patient presents with a sad mood and anxious affect. He is cooperative but mildly tearful. His speech is normal in rate, tone, and volume. He has a congruent affect, and his thought processes are logical and goal-directed. His thought content is negative, with recurrent suicidal ideation. He denies any perceptual disturbances. The patient’s cognition is intact, with good insight and judgment.(Depression SOAP Note Essay Example)
Diagnostic Impression:
- 296.23 (F32.2), single episode, Severe Major Depressive Disorder (MDD) – MDD is characterized by symptoms such as depressed mood, diminished pleasure in certain activities which were previously enjoyed, weight loss or gain, difficulty with sleep, observed psychomotor retardation or agitation, loss of energy, limited ability to concentrate, indecisiveness, thoughts of death, and worthlessness (American Psychiatric Association [APA], 2019).
- 309.0 (F43.21), Adjustment Disorder with depressed mood – The client’s presentation also suggests AD with depressed mood. AD is characterized by emotional and behavioral symptoms towards known stressors (APA, 2019). These symptoms include excessive stress and impaired social and occupational functioning with predominant tearfulness, hopelessness, and low mood.(Depression SOAP Note Essay Example)
- 292.84 (F19.24), Uknown Substance-Induced Depressive Disorder (SIDD) – SIDD is characterized by mood disturbance causing diminished pleasure in activities with evidence of substance use during the episode, and the substance is capable of causing mood disturbance (APA, 2019).(Depression SOAP Note Essay Example)
Reflections: MDD is the primary diagnosis. The patient’s presentation is consistent with a single episode, severe MDD. AD and SIDD are considered but ruled out due to the patient’s history, clinical presentation, and negative drug screen. The patient’s suicidal ideation and depressive symptoms are concerning, which necessitates prompt treatment. MDD is associated with higher suicide incidence (Dong et al., 2019). It is crucial to consider the patient’s history of high cholesterol and type 2 diabetes, which may contribute to his overall health and well-being. Additionally, it is important to address his mental health concerns in conjunction with his physical health. Lastly, nurses should assess the patient’s safety, implement a safety plan, and involve the patient’s supportive family members in his treatment plan.(Depression SOAP Note Essay Example)
Case Formulation and Treatment Plan:
- Continue Lexapro 10 mg PO daily. Lexapro is well-tolerated and effective in treating MDD symptoms (Wang et al., 2021). The patient’s medication will be reviewed in 2 weeks.
- Start psychotherapy (CBT) twice a week – Cognitive behavioral therapy CBT effectively manages MDD symptoms (Cuijpers et al., 2016).(Depression SOAP Note Essay Example)
- Safety plan – The patient will be assessed for suicidal ideation and safety at each appointment. A safety plan has been established for the patient, and the patient’s wife is supportive and involved in his care.
- Education – Encourage the patient to make lifestyle modifications such as exercise and dietary changes to improve his health. The potential side effects of medication, as well as(Depression SOAP Note Essay Example)
Referrals – Refer the patient to an endocrinologist to manage the patient’s diabetes and cholesterol.
PRECEPTOR VERIFICATION:
I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.(Depression SOAP Note Essay Example)
Preceptor signature: ________________________________________________________
Date: ________________________
References
American Psychiatric Association. (2019). Diagnostic and statistical manual of mental disorders (7th ed.). American Psychiatric Publishing, Inc. (Depression SOAP Note Essay Example)
Cuijpers, P., Cristea, I. A., Karyotaki, E., Reijnders, M., & Huibers, M. J. (2016). How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence. World Psychiatry: Official Journal Of The World Psychiatric Association (WPA), 15(3), 245–258. https://doi.org/10.1002/wps.20346
Dong, M., Zeng, L. N., Lu, L., Li, X. H., Ungvari, G. S., Ng, C. H., Chow, I. H. I., Zhang, L., Zhou, Y., & Xiang, Y. T. (2019). Prevalence of suicide attempt in individuals with major depressive disorder: a meta-analysis of observational surveys. Psychological Medicine, 49(10), 1691–1704. https://doi.org/10.1017/S0033291718002301
Wang, X., Fan, Y., Li, G., & Li, H. (2021). The efficacy of escitalopram in major depressive disorder: a multicenter randomized, placebo-controlled double-blind study. International Clinical Psychopharmacology, 36(3), 133–139. https://doi.org/10.1097/YIC.0000000000000350(Depression SOAP Note Essay Example)
Frequently Asked Questions
What is a good introduction of depression?
Depression is a complex and pervasive mental health condition that affects millions of individuals worldwide. It goes beyond occasional feelings of sadness, often encompassing persistent low mood, loss of interest or pleasure in activities, and a range of physical and cognitive symptoms. This condition can impact daily functioning, relationships, and overall well-being, requiring a comprehensive approach to diagnosis, treatment, and support. Understanding depression’s multifaceted nature is crucial in addressing its challenges and promoting mental health awareness.(Depression SOAP Note Essay Example)
What is an example of a topic about depression?
An example of a topic about depression is “The Impact of Exercise on Managing Symptoms of Depression.” This topic explores how regular physical activity can potentially alleviate depressive symptoms and improve overall mental well-being. It delves into scientific studies, anecdotal evidence, and potential mechanisms behind the positive effects of exercise on mood regulation. Additionally, the discussion might encompass various forms of physical activity, recommended routines, and the importance of a holistic approach to mental health treatment.(Depression SOAP Note Essay Example)
What is a good description of a depression?
Depression is a complex mental health condition characterized by persistent feelings of sadness, emptiness, and a lack of interest or pleasure in activities once enjoyed. It often brings about changes in sleep patterns, appetite, and energy levels, along with difficulties in concentrating and making decisions. Individuals with depression may experience physical symptoms such as fatigue and aches, and it can impact daily functioning, relationships, and overall quality of life. It’s important to seek professional help for accurate diagnosis and effective treatment.(Depression SOAP Note Essay Example)
How do you write a good SOAP note for mental health?
A well-crafted SOAP note for mental health begins with a concise Subjective section, capturing the client’s presenting issues, emotions, and any relevant contextual information. The Objective section should include observed behaviors, mood assessment, and pertinent data from any assessments or tests. In the Assessment section, the clinician should offer a professional analysis of the client’s condition, considering relevant diagnoses, progress, and potential challenges. Conclude with a comprehensive Plan, outlining treatment goals, therapeutic interventions, medications (if applicable), and any follow-up appointments or referrals to ensure effective and holistic care.(Depression SOAP Note Essay Example)
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