Unit 14 Assignment – Clinical: SOAP Note

Instructions

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.(Mental Health Clinical Soap Note Essay for Nursing Students)

Note: Grades of Incomplete on this assignment will result in a clinical failure.

Rubric

NU675 Unit 14 Assignment – Clinical: SOAP Note

NU675 Unit 14 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.(Mental Health Clinical 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(Mental Health Clinical 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.(Mental Health Clinical 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.(Mental Health Clinical 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.(Mental Health Clinical Soap Note Essay for Nursing Students)

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.

2 pts

Total Points: 20

Mental Health Clinical Soap Note Essay for Nursing Students

CC: “I am just feeling flat. Am losing it.” Clinical SOAP Note

Subjective:

HPI: SM is a 15-year-old African American female presenting to the clinic for counseling. “I am just feeling flat. Am losing it.” SM reports that she does not want to return to school, but her parent insists. SM had sent her boyfriend some explicit pictures a few weeks ago, and he showed them to his friend, who uploaded them online and sent them to the school group. “I never thought she would do that to me.” The school found out, and the matter is with the police, but SM is worried about her public image and what the parents would do if they found out. She is receiving bullying messages and posts on social media, referring to her as a slut. “I think I am a slut, a worthless slut.” Since she watched the videos four days ago, she has not returned to school and has been experiencing flashbacks of the day she made the recordings and willingly sent them to her boyfriend. She laments watching her videos on social media. Everyone knows about me. “I can’t wipe them off my memories, and anytime I watch a movie or video, I keep having flashbacks of these memories. SM has tried various ways to be happy in vain. She is unsatisfied with herself and avoids watching videos or movies with her family or on social media. She spends most of her time in her room. “I don’t have the energy to walk or talk to anyone. I cannot catch or retain sleep at night either.” She finds it hard to concentrate on things that make her happy, including her academic performance. She is thinking of dyeing but does not know how. “I want to die, but I would appreciate intervention to help me overcome all these.(Mental Health Clinical Soap Note Essay for Nursing Students)

Past Medical Hx:

• Current Medications: No current medications
• Medication trials:
• Psychiatric diagnosis:
• Allergies: NKDA

Family Hx: Lives with both parents, who are professionals and workaholics. She has a younger brother. No known health conditions among family members.(Mental Health Clinical Soap Note Essay for Nursing Students)

Substance Use Hx: Denies any drug and substance abuse.

Personal and Social Hx: She is in grade 10 and not working. Has no legal history. Likes playing guitar and painting art.

ROS:

GENERAL: No weight loss, fever, or chills.

HEENT: No visual or hearing problems. No nasal congestion or sore throat.

SKIN: No skin rash or itching.   

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

RESPIRATORY: No dyspnea or productive cough.(Mental Health Clinical Soap Note Essay for Nursing Students)

GASTROINTESTINAL: No anorexia or abdominal pain.

GENITOURINARY: No dysuria or urinary frequency. 

HEMATOLOGIC: No anemia or easy bruising/bleeding.

LYMPHATICS: No enlarged nodes.

NEUROLOGICAL: No headache or dizziness. No numbness or tingling in the extremities. No changes in bladder control or bowel movement.

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

ENDOCRINOLOGIC: No polyuria or polydipsia.

PSYCHOLOGICAL: Reports anxiety, depression, and suicide ideation.

Objective:

Vital Signs: Temp: 98.5 F, BP: 117/73, R: 17, HR: 85, O2: 98, Ht: 5’3″, Wt.: 117 lbs., BMI = 20.7 kg/m², healthy weight.

Diagnostic results: NA

Mental Status Examination:  SM is alert and oriented in all spheres. She is well-kempt. She is calm and interactive and appears to be in acute psychological distress. She avoids eye contact. He stated that mood is congruent with affect. Her emotional range is expansive. She is resourceful and has difficulty maintaining concentration and attention during the examination. Has normal insight and judgment. Cognition and memory are intact with the ability to abstract. Suicide ideation is present with no plan or intent. The client has a low risk of self-harm or harm to others.(Mental Health Clinical Soap Note Essay for Nursing Students)

Diagnostic Impression:

1. Acute Stress Disorder (ASD) – 3 (F43.0)

ASD is characterized by symptoms associated with clinical impairment or distress in significant areas of life due to exposure to actual or threatened sexual violation, injury, or death, and symptoms present from 3 days to one month (American Psychiatric Association [APA], 2019). Individuals experience symptoms such as intrusive memories or/and recurrent dreams of the traumatic event, flashbacks of the traumatic event, inability to experience positive emotions, altered sense of reality, inability to avoid feelings, thoughts, or memories related to the event, sleep disturbance, irritability, a problem with concentration, and hypervigilance. SM presents most of these symptoms. This is the primary diagnosis.(Mental Health Clinical Soap Note Essay for Nursing Students)

2. Major Depressive Disorder (MDD) – 21 (F32.0)

MDD is characterized by loss of pleasure/interest or depressed mood presenting within two weeks (APA, 2019). Individuals experience psychomotor agitation, reduced interest in particular or all activities, depressed mood, hypersomnia/insomnia, fatigue, worthlessness, reduced ability to concentrate, and recurring thoughts of death. This is a secondary diagnosis.(Mental Health Clinical Soap Note Essay for Nursing Students)

3. Generalized Anxiety Disorder (GAD) – 02 (F41.1)

GAD is characterized by worry and anxiety and difficulty controlling worry, leading to clinical impairment or distress in significant areas of functioning (APA, 2019). Individuals experience symptoms such as muscle tension, restlessness, inability to concentrate, irritability, and sleep disturbance presenting in at least six months. This is a secondary diagnosis.(Mental Health Clinical Soap Note Essay for Nursing Students)

Reflections:

Acute Stress Disorder is the primary diagnosis in this case. The client presents symptoms such as restlessness, worthlessness, fatigue, social isolation, avoidance, unhappiness, persistent distressing memories, dreams, flashbacks, regrets, and worry, which meet the diagnostic criteria for ASD. MDD is a secondary diagnosis considering the client’s symptoms have not been experienced in two weeks. Moreover, MDD is marked by a loss of pleasure in all activities (APA, 2019), yet SM engages in certain activities to forget her predicament. Equally, GAD is given as a secondary diagnosis considering the client’s symptoms have not been experienced for at least six months. Moreover, GAD is marked by excessive worry (APA, 2019), yet the client’s worry is relevant to her situation.(Mental Health Clinical Soap Note Essay for Nursing Students)

Treatment Plan: 

Goals

• Reduce symptoms of ASD.(Mental Health Clinical Soap Note Essay for Nursing Students)
• Practice interpersonal conflict resolution skills.
• Identify and connect feelings with relevant reactions.
• Develop a willingness to take responsibility for her actions.

Interventions

Pharmacological

#99204

Start Paroxetine 20mg once a day. Paroxetine is effective and appropriate for treating PSTD, whose symptoms are similar to ASD (Fanai & Khan, 2020).(Mental Health Clinical Soap Note Essay for Nursing Students)

Non-Pharmacological

#98960

Explain to the patient that her current condition can happen to anyone and that suicide is not a solution. Remind the client that you are there for them and that they did well-seeking help, and everything will fall into place. Discuss with the client the need to inform the parents about the situation or have them come to the clinic for family counseling. Discuss with the client the importance of maintaining appropriate relationships.(Mental Health Clinical Soap Note Essay for Nursing Students)

Refer the patient to a psychiatrist for CBT. CBT allows teenagers to shift their thought patterns relating to a traumatic event and learn new coping mechanisms to use in situations that provoke traumatic events (Gökkaya, 2017). Besides, CBT can reduce the risk of developing post-traumatic stress disorder (Fanai & Khan, 2020). Significantly, the client desires to live normally, and CBT will be ideal for helping her achieve better health outcomes.(Mental Health Clinical Soap Note Essay for Nursing Students)

Discharge: After seven days.

Table 1: Medical Decision Making Table

CPT Code	Level of MDM	Number and Complexity of Problems	Amount and/or Complexity of Data to be Reviewed and Analyzed (Mental Health Clinical Soap Note Essay for Nursing Students)	Risk of Complications and/or Morbidity/Mortality of Patient Management
99211	Low	Low Acute stress disorder with depressed mood.	Category 1: Tests and Documents Review of patient medical history.	Low Risk New patient seen for evaluation and counselling (Mental Health Clinical Soap Note Essay for Nursing Students)

References

American Psychiatric Association. (2019). Diagnostic and statistical manual of mental disorders  (7^th ed.). American Psychiatric Publishing, Inc.   (Mental Health Clinical Soap Note Essay for Nursing Students)

Fanai, M., & Khan, M. A. (2020). Acute stress disorder. Available at: https://www.ncbi.nlm.nih.gov/books/NBK560815/ (Accessed 28 November 2022)

Gökkaya, F. (2017). Peer bullying in schools: A cognitive behavioral intervention program. Child and Adolescent Mental Health, 9. http://dx.doi.org/10.5772/66701