Focused Soap Note for Anxiety Essay Example

FOCUSED SOAP NOTE FOR ANXIETY, PTSD, AND OCD

In assessing patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders, you will continue the practice of looking to understand chief symptomology in order to develop a diagnosis. With a differential diagnosis in mind, you can then move to a treatment and follow-up plan that may involve both psychopharmacologic and psychotherapeutic approaches. 

In this Assignment, you use a case study to develop a focused SOAP note based on evidence-based approaches. 

NRNP_6675_Week3_Assignment_Rubric

NRNP_6675_Week3_Assignment_Rubric

Criteria

Ratings

Pts

This criterion is linked to a Learning OutcomeCreate documentation in the Focused SOAP Note Template about your assigned patient.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

15 to >13.0 pts

Excellent 90%–100%

The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.

13 to >11.0 pts

Good 80%–89%

The response accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.

11 to >10.0 pts

Fair 70%–79%

The response describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis but is somewhat vague or contains minor innacuracies.

10 to >0 pts

Poor 0%–69%

The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Or the subjective documentation is missing.

15 pts

This criterion is linked to a Learning OutcomeIn 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

15 to >13.0 pts

Excellent 90%–100%

The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.

13 to >11.0 pts

Good 80%–89%

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.

11 to >10.0 pts

Fair 70%–79%

Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.

10 to >0 pts

Poor 0%–69%

The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed. Or the objective documentation is missing.

15 pts

This criterion is linked to a Learning OutcomeIn 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.

20 to >17.0 pts

Excellent 90%–100%

The response thoroughly and accurately documents the results of the mental status exam…. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected.

17 to >15.0 pts

Good 80%–89%

The response accurately documents the results of the mental status exam…. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the disorders selected.

15 to >13.0 pts

Fair 70%–79%

The response documents the results of the mental status exam with some vagueness or innacuracy…. Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vagueness or innacuracy.

13 to >0 pts

Poor 0%–69%

The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or the assessment documentation is missing.

20 pts

This criterion is linked to a Learning OutcomeIn the Plan section, provide:• Your plan for psychotherapy• 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. • Incorporate one health promotion activity and one patient education strategy.

25 to >22.0 pts

Excellent 90%–100%

The response provides an evidence-based, detailed, and appropriate plan for psychotherapy for the patient…. The response provides an evidence-based, detailed, and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A strong rationale for the plan is provided that demonstrates critical thinking and content understanding…. The response includes at least one evidence-based health promotion activity and one evidence-based patient education strategy.

22 to >19.0 pts

Good 80%–89%

The response provides an evidence-based and appropriate plan for psychotherapy for the patient…. The response provides an evidence-based and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. An adequate rationale for the plan is provided…. The response includes at least one health promotion activity and one patient education strategy.

19 to >17.0 pts

Fair 70%–79%

The response provides a somewhat vague or inaccurate plan for psychotherapy for the patient…. The response provides a somewhat vague or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is weak or general…. The response includes one health promotion activity and one patient education strategy, but it may contain some vagueness or innacuracy.

17 to >0 pts

Poor 0%–69%

The response provides an incomplete or inaccurate plan for psychotherapy for the patient…. The response provides an incomplete or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is inaccurate or missing…. The health promotion and patient education strategies are incomplete or missing.

25 pts

This criterion is linked to a Learning Outcome• Discussion include what may be done differently with this patient if student conducted the session again. Discussed the next intervention if you could follow up with this patient. The discussion was related to legal/ethical considerations (demonstrated critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention that take into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

5 to >4.0 pts

Excellent 90%–100%

Reflections are thorough, thoughtful, and demonstrate critical thinking. Reflections contain a discussion of all elements described within assignment directions.

4 to >3.5 pts

Good 80%–89%

Reflections demonstrate critical thinking. Reflections contain 2 out of 3 (legal/ethical considerations, social determinate of health, health promotion) with consideration of patient factors and risk factors.(Focused Soap Note for Anxiety Essay Example)

3.5 to >3.0 pts

Fair 70%–79%

Reflections are somewhat general or do not demonstrate critical thinking. Reflections contain 2 out of 3 (legal/ethical considerations, social determinate of health, health promotion) without consideration of patient factors and risk factors.

3 to >0 pts

Poor 0%–69%

Reflections are incomplete, inaccurate, or missing.

5 pts

This criterion is linked to a Learning OutcomeProvide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).(Focused Soap Note for Anxiety Essay Example)

10 to >8.0 pts

Excellent 90%–100%

The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making.(Focused Soap Note for Anxiety Essay Example)

8 to >7.0 pts

Good 80%–89%

The response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study.

7 to >6.0 pts

Fair 70%–79%

Three evidence-based resources are provided to support the assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification.(Focused Soap Note for Anxiety Essay Example)

6 to >0 pts

Poor 0%–69%

Two or fewer resources are provided to support the assessment and diagnosis decisions. The resources may not be current or evidence based.

10 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for parenthetical/in-text citations and reference list.(Focused Soap Note for Anxiety Essay Example)

5 to >4.0 pts

Excellent 90%–100%

Uses correct APA format with no errors

4 to >3.5 pts

Good 80%–89%

Contains 1-2 APA format for parenthetical/in-text citations and reference list errors

3.5 to >3.0 pts

Fair 70%–79%

Contains 3-4 APA format for parenthetical/in-text citations and reference list errors

3 to >0 pts

Poor 0%–69%

Contains five or more APA format for parenthetical/in-text citations and reference list errors

5 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and punctuation(Focused Soap Note for Anxiety Essay Example)

5 to >4.0 pts

Excellent 90%–100%

Uses correct grammar, spelling, and punctuation with no errors

4 to >3.5 pts

Good 80%–89%

Contains 1-2 grammar, spelling, and punctuation format errors

3.5 to >3.0 pts

Fair 70%–79%

Contains 3-4 grammar, spelling, and punctuation format errors

3 to >0 pts

Poor 0%–69%

Contains five or more grammar, spelling, and punctuation format errors that interfere with the reader’s understanding

5 pts

Total Points: 100

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·       Walden University. (2021). Case study: Dev Cordoba. Walden University Canvas. https://waldenu.instructure.com

Case study: Dev Cordoba.  Canvas. https://waldenu.instructure.com

Video transcript.

DR. JENNY: Hi there. My name is Dr. Jenny.

Can you tell me your name and how old you are?

DEV CORDOBA: My name is Dev,

and I am seven years old.(Focused Soap Note for Anxiety Essay Example)

DR. JENNY: Wonderful. Dev, can you tell me what

the month and the date is? And where are we right now?

DEV CORDOBA: Today is St. Patrick’s Day. It’s March 17th.

DR. JENNY: Do you know where we are?

DEV CORDOBA: We’re at the school.

DR. JENNY: Good. Did your mom tell you why

you’re here today to see me?(Focused Soap Note for Anxiety Essay Example)

DEV CORDOBA: She thought you were going to help me be better.

DR. JENNY: Yes, I am here to help you. Have you ever come to see

someone like me before, or talked to someone like

me before to help you with your mood?

DEV CORDOBA: No, never.

DR. JENNY: OK. Well, I would like to start with getting to know you a little bit better, if that’s OK. What do you like to do for

fun when you’re at home?(Focused Soap Note for Anxiety Essay Example)

DEV CORDOBA: Oh, I have a dog. His name is Sparky. We play policeman in my room. And I have LEGOs, and I could build something if you want.

DR. JENNY: I would love to see what you build with your LEGOs. Maybe you can bring that

in for me next appointment.

Who lives in your home?(Focused Soap Note for Anxiety Essay Example)

DEV CORDOBA: My mom and my baby brother and Sparky.

DR. JENNY: Do you help your mom with your brother?

DEV CORDOBA: No. His breath smells like

bad milk all the time. [CHUCKLES] And he(Focused Soap Note for Anxiety Essay Example)

cries a lot, and my mom spends more time with him.

DR. JENNY: So how do you feel most of the time? Do you feel sad or

worried or mad or happy?

DEV CORDOBA: Worried.(Focused Soap Note for Anxiety Essay Example)

DR. JENNY: What types of things do you worry about?

DEV CORDOBA: I don’t know, just everything. I don’t know.

DR. JENNY: OK. So your mom tells me you also have a lot of bad dreams. Can you tell me a little

more about your bad dreams, like maybe what they’re about, how many nights you might have them?

DEV CORDOBA: I dream a lot that I’m lost, that I can’t find my mom or my little brother. They seem like they happen almost every night, but maybe not some nights.(Focused Soap Note for Anxiety Essay Example)

DR. JENNY: Now that must feel horrible. Have you ever been lost before when maybe you weren’t asleep? DEV CORDOBA: Oh, no. No. And I don’t like the dark. My mom puts me in a night

light with the door open, so I know she’s really there.

DR. JENNY: That seems like that probably would help. Do you like to go to school? Or would you rather not go? DEV CORDOBA: I worry about by mom and brother when I’m at school. All I can think about

is what they’re doing, and if they’re OK. And besides, nobody(Focused Soap Note for Anxiety Essay Example)

likes me there. They call me Mr. Smelly. DR. JENNY: Well. That’s not nice at all. Why do you feel

they call you names? DEV CORDOBA: I don’t know. But my mom says it’s because

I won’t take my baths. [SIGHS] She tells(Focused Soap Note for Anxiety Essay Example)

me to, and it– and I have night accidents. DR. JENNY: Oh, how does

that make you feel? DEV CORDOBA: Sad and really bad. They don’t know how it feels for

their daddy to never come home. What if my mom

doesn’t come home too? DR. JENNY: Yes, you seem(Focused Soap Note for Anxiety Essay Example)

to worry about that a lot. Does this worry stop you from

being able to learn in school? DEV CORDOBA: Well, [SIGHS]

my teacher is, all the time, telling me to sit

down and focus. And I get in trouble for(Focused Soap Note for Anxiety Essay Example)

[SIGHS] looking out the window. And she moved my

chair beside her desk, but I don’t mind because

Billy leaves me alone now. DR. JENNY: Billy. Have you ever hit

Billy or anyone else? DEV CORDOBA: No, but I(Focused Soap Note for Anxiety Essay Example)

did throw my book at him. DR. JENNY: Hmm. DEV CORDOBA: [CHUCKLES] DR. JENNY: What about yourself? Have you ever hit yourself or

thought about doing something to hurt yourself? DEV CORDOBA: No. DR. JENNY: OK. Well, Dev, I would like

to talk to your mom now. We’re going to work(Focused Soap Note for Anxiety Essay Example)

together, and we’re going to help you feel

happier, less worried, and be able to(Focused Soap Note for Anxiety Essay Example)

enjoy school more. Is that OK? DEV CORDOBA: Yes. Thank you. MISS CORDOBA: Hi. DR. JENNY: Thank you, Miss

Cordoba, for bringing in Dev. I feel we can help him. So tell me, what is your

main concerns for Dev? MISS CORDOBA: [SIGHS] Well,(Focused Soap Note for Anxiety Essay Example)

he just seems so anxious and worried all the time, silly

things like I’m going to die, or I won’t pick

him up from school. He says I love his

brother more than him. He’ll throw things

around the house, and gets in trouble at(Focused Soap Note for Anxiety Essay Example)

school for throwing things. He has a difficult

time going to sleep. He wants his lights on, doors

open, gets up frequently. And he’s all the time(Focused Soap Note for Anxiety Essay Example)

wanting to come home from school, claims stomach

aches, and headaches almost daily. He won’t eat. He’s lost three pounds

in the past three weeks. Our pediatrician sent us to(Focused Soap Note for Anxiety Essay Example)

you because he doesn’t believe anything is physically wrong. Oh, and I almost forgot. He still wets the bed at night. [SIGHS] We’ve tried everything. His pediatrician

did give him DDVAP, but it doesn’t seem to help. DR. JENNY: Hmm. OK. Can you tell me,

any blood relatives have any mental health(Focused Soap Note for Anxiety Essay Example)

or substance use issues? MISS CORDOBA: No, not really. DR. JENNY: What

about his father? He said that he never came home? MISS CORDOBA: Oh, yes. His father was deployed with

the military when Dev was five. I told Dev he was on vacation. I didn’t know what to tell him. I thought he was too

young to know about war. And his father was

killed, so Dev still doesn’t understand that his

father didn’t just leave him. [SIGHS] I just feel so guilty

that all of this is my fault. DR. JENNY: Miss Cordoba,(Focused Soap Note for Anxiety Essay Example)

you did the right thing by bringing in Dev. We can help you with him.

MISS CORDOBA: Oh, thank you. [MUSIC PLAYING]

Focused Soap Note for Anxiety Essay Example

Focused Soap Note for Anxiety, PTSD, AND OCD

Subjective:

CC: “She thought you would help me get better.”

HPI: DC is a 7-year-old male present for mental health assessment in the mother’s company. DC denies previous psychiatric evaluation and resorts to persistent worry about everything. The client reports dreaming that he is lost every night. During such dreams, he cannot find his mother and little brother. He despises darkness and sleeps with the door open and the night light on. He does not like school, and fellow pupils call him Mr Smelly as he does not like taking a bath. He reported feeling sad and bad, partly because of his father’s absence, and worried his mother would never return. While at school, he keeps looking out the window and has difficulty sitting and focusing. The mother reports that DC worries about her death and not coming to pick him up from school. The mother further says that DC complains about the more love the brother gets from her. He throws things while at the house and in school. He has difficulty going to sleep and wakes up frequently. He always wants to go home, complaining of headache and stomach ache almost daily. He does not eat and lost 3 lbs over the last three weeks.(Focused Soap Note for Anxiety Essay Example)

Past Psychiatric History:

General Statement: This is the first time the client has entered treatment for mood problems.

Caregivers: Mother.

Hospitalizations: No history of hospitalization, detox, or self-harm.

Medication trials: DDVAP to help with bed wetting.(Focused Soap Note for Anxiety Essay Example)

Psychotherapy or Previous Psychiatric Diagnosis: No previous mental health diagnosis.

Substance Use History: No history of substance abuse was reported.(Focused Soap Note for Anxiety Essay Example)

Family Psychiatric/Substance Use History:  No blood relative with a mental health history. No substance use history was reported. 

Social History: He lives with her mother and younger brother. Father was killed in service when he was five. He likes playing with her dog and LEGOs. No safety issues on record.(Focused Soap Note for Anxiety Essay Example)

Medical History:

Current Medications: No current medications.

Allergies: NKFDA

Reproductive Hx: NA.

ROS:

GENERAL: 3-pound weight loss. No fatigue, fever, or chill.

HEENT: Eyes: No visual problems. Ears, Nose, Throat: No hearing or nasal concerns. No difficulty swallowing.

SKIN: No skin rashes.

CARDIOVASCULAR: No chest pain or discomfort.

RESPIRATORY: No breathing complications.(Focused Soap Note for Anxiety Essay Example)

GASTROINTESTINAL: No nausea, vomiting, or diarrhea.

GENITOURINARY: No Urinary hesitancy, dysuria, or hematuria.

NEUROLOGICAL: No tingling in the extremities. No headache or numbness.

MUSCULOSKELETAL: No back pain, muscle stiffness, or joint pain.

HEMATOLOGIC: No anemia, bleeding, or bruising.(Focused Soap Note for Anxiety Essay Example)

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No heat or sweat hypersensitivity or Hyperhidrosis. No polyuria or polydipsia.

Physical Exam: NA

Diagnostic results: Providing a Child Behavior Checklist (CBC) and requesting Teacher Report Form (TRF) would provide supplementary information for a definitive diagnosis. Both tools rate a child’s behavioral and emotional problems at home and school and are effective for children between 6 and 18 years (Thapar et al., 2015).(Focused Soap Note for Anxiety Essay Example)

Assessment

Mental Health Examination: The client is appropriately dressed and oriented to person, time, space, and event. He is conversant and interactive. He reports feeling worried, and the effect s congruent with the mood. He is attentive, but eye contact is avoidant. No visual or auditory hallucinations were noted during the exam. Memory and cognition are intact. Judgment and insights are normal. He denies self-harming behaviors toward himself or others. No suicide ideation was noted to the am, and the client is not at risk of self-harm or harming others.(Focused Soap Note for Anxiety Essay Example)

Differential Diagnosis

1. 02 (F41.1), Generalized Anxiety Disorder: The diagnostic criteria include persistent worry/anxiety about many things lasting at least six months and challenging to control (American Psychiatric Association [APA], 2019). Affected people experience at least three or more symptoms, such as restlessness, muscle rigidity, difficulty concentrating, fatigue, or sleeplessness. These symptoms are clinically significant, affect important areas of functioning, and are not attributed to other medical conditions or effects of substance abuse.(Focused Soap Note for Anxiety Essay Example)
2. 28 (F43.23), Adjustment Disorders, with mixed anxiety and depressed mood: Adjustment disorder is marked by behavioral or emotional symptoms against a stressor presenting within three months (APA, 2019). Affected individuals experience marked distress and impaired important areas of functioning. Moreover, the symptoms are not attributed to normal bereavement, other mental health disorders, or medical conditions.(Focused Soap Note for Anxiety Essay Example)
3. 81 (F43.10), Posttraumatic Stress Disorder: Posttraumatic stress disorder (PTSD) is characterized by threatened or real experience with injury, death, or sexual violence either directly, witnessing, learning about the event, or repeated exposure (APA, 2019). Individuals experience one or more symptoms, such as intrusive and recurrent distressing dreams/memories, flashbacks, prolonged or intense psychological distress, and marked physiological reactions to similar stimuli. Individuals also experience altered cognition and mood and develop altered reactivity and arousal associated with traumatic events. These symptoms are experiences following the traumatic experience, and individuals develop persistent avoidance of stimuli related to such events.(Focused Soap Note for Anxiety Essay Example)

Reflection

In a similar case, I would interview the child alone and in a safe room to promote a sense of confidentiality and acquire more information the client would not have provided in the mother’s presence. In this case, GAD is the primary diagnosis since the client presents symptoms that meet its diagnostic criteria, such as persistent sadness and worry, irritability, difficulty concentrating, nightmares, and weight loss. DC increasingly worries about everything, including his mother and brothers (Walden University, 2021). Particularly, he worries that his mother will one day leave and never return like his father. GAD is characteristically associated with worry about many things and is difficult to control (Sadock et al., 2015). The worry affects his concentration in school and causes irritability, as the mother reports him throwing things around the house.(Focused Soap Note for Anxiety Essay Example)

However, the client has a combined presentation of depression and anxiety. People with AD respond emotionally to stressful events (Sadock et al., 2015). In this case, the client’s mood issues are related to two perceived stressful events. One, the client is concerned that the brother is receiving more attention from the brother than he is. Two, the client is affected by the fact that the father left and never returned. As a result, he experiences emotional outbursts and relationship problems with his brother and other pupils at school. However, this diagnosis is refuted as GAD better explains the symptoms.(Focused Soap Note for Anxiety Essay Example)

Moreover, the client’s symptoms suggest PSTD. While most traumatic events are associated with traumatic experiences, individuals, particularly children, can act uncharacteristically against the loss of a parent and consequently as part of grief and consequently develop emotional and behavioral responses to such absence such as irritability, engaging in risky behavior, lose interest in things, and worry about the surviving parent. Although children are vulnerable to psychosocial adversity (Centers for Disease Control and Prevention, 2020; Thapar et al., 2015), the client’s symptoms do not meet the diagnostic criterion for PTSD.(Focused Soap Note for Anxiety Essay Example)

The ethical aspects in this case scenario are informed consent and confidentiality. The client’s capacity for an informed decision is limited, and the practitioner must provide the parent with consent and use language that the parent and the client can understand to promote informed decisions. Moreover, the practitioner should ensure the client’s clinical information is not disclosed to any third party except the parents and other personnel as guided by legislation and circumstances.(Focused Soap Note for Anxiety Essay Example)

Treatment Plan

1. Pharmacotherapy – Initiate Buspirone 5 mg PO QID for GAD. Buspirone is effective for GAD and well tolerated in pediatric patients (Strawn et al., 2018). The dosage can be increased depending on the client’s response.(Focused Soap Note for Anxiety Essay Example)
2. Psychotherapy – Initiate parent-child cognitive behavioral therapy (CBT). Parent-child CBT is recommended as an effective intervention for anxiety disorders in children ages four and seven (Alvarez et al., 2018). At least six sessions in which the parent and the child are. Sadock et al. (2015) acknowledge parental involvement in pediatric therapy and the effectiveness of interactive parent-child therapy in mitigating behavioral and emotional issues for children below nine years.(Focused Soap Note for Anxiety Essay Example)
3. Education: Educate the parent on the anxiety symptoms, available treatment, benefits, and risks. Discuss with the client’s parents the importance of an appropriate diet to gain weight.(Focused Soap Note for Anxiety Essay Example)

RTC: After two weeks.

Frequently Asked Questions

What are the 5 types of coping strategies for anxiety?

The five types of coping strategies for anxiety include cognitive strategies (changing thought patterns), behavioral strategies (engaging in calming activities), relaxation techniques (deep breathing, meditation), social support (seeking help from friends or family), and physical well-being strategies (exercise, maintaining a healthy lifestyle).(Focused Soap Note for Anxiety Essay Example)

What skills reduce anxiety?

Skills that can help reduce anxiety include mindfulness meditation, deep breathing exercises, and cognitive reframing techniques, which promote relaxation, emotional regulation, and a more positive perspective on stressors.(Focused Soap Note for Anxiety Essay Example)

How do you write a good SOAP note for mental health?

A well-crafted SOAP note for mental health should succinctly outline the Subjective (client’s self-reported experiences and feelings), Objective (clinician’s observations and measurable data), Assessment (professional analysis and diagnosis), and Plan (treatment strategy and interventions) aspects of the client’s session, ensuring clear and comprehensive documentation of their mental health status and therapeutic path.(Focused Soap Note for Anxiety Essay Example)

What are SOAP notes in mental health?

SOAP notes in mental health are a structured form of clinical documentation used by mental health professionals to record patient interactions and treatment plans. The acronym stands for Subjective, Objective, Assessment, and Plan, representing the key components of a comprehensive note that includes the patient’s reported experiences, the therapist’s observations, clinical assessments, and the proposed course of treatment.

References

Alvarez, E., Puliafico, A., Leonte, K. G., & Albano, A. M. (2018). Psychotherapy for anxiety disorders in children and adolescents. Available at: http://www.uptodate.com/  (Retrieved 5 March 2023)

American Psychiatric Association (APA). (2019). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Publishing

Centers for Disease Control and Prevention. (2020, 3 April). Adverse childhood experiences (ACEs) Links to an external site. [Video]. https://www.cdc.gov/violenceprevention/aces/index.html

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer. 

Strawn, J. R., Mills, J. A., Cornwall, G. J., Mossman, S. A., Varney, S. T., Keeshin, B. R., & Croarkin, P. E. (2018). Buspirone in children and adolescents with anxiety: a review and Bayesian analysis of abandoned randomized controlled trials. Journal of child and adolescent psychopharmacology, 28(1), 2-9. https://doi.org/10.1089/cap.2017.0060

Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (Eds.). (2015). Rutter’s child and adolescent psychiatry (6th ed.). Wiley Blackwell. 

Walden University. (2021). Case study: Dev Cordoba. Walden University Canvas. https://waldenu.instructure.com