Mental Health Soap Note

Mental Health Soap Note

In Weeks 4, 7, and 9 of the course, you will participate in clinical discussions called grand rounds. In one of these three weeks, you will be a presenter as well as help facilitate the online discussion; in the others you will be an active discussion participant. When it is your week to present, you will create a Focused SOAP note and a short didactic (teaching) video presenting a real (but de-identified) complex patient case from your practicum experience.(Mental Health Soap Note Essay Example)

You should have received an assignment from your Instructor letting you know which week of the course you are assigned to present. 

Assessing a Patient with Depressive Symptoms

RESOURCES

Be sure to review the Learning Resources before completing this activity. Click the weekly resources link to access the resources. 

WEEKLY RESOURCES

TO PREPARE: 

  • Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
  • Select a child/adolescent or adult patient from your clinical experience that presents with a significant concern. Create a focused SOAP note for this patient using the template in the Resources. All SOAP notes must be signed by your Preceptor. When you submit your SOAP note, you should include the complete SOAP note as a Word document and PDF/images of completed assignment signed by your Preceptor. You must submit your SOAP Note using Turnitin.Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.(Mental Health Soap Note Essay Example)
  • Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice what you will say beforehand, and ensure that you have the appropriate lighting and equipment to record the presentation.
  • Your presentation should include objectives for your audience, at least 3 possible discussion questions/prompts for your classmates to respond to, and at least 5 scholarly resources to support your diagnostic reasoning and treatment plan.

Video assignment for this week’s presenters:

Record yourself presenting the complex case study for your clinical patient. In your presentation:

  • Dress professionally and present yourself in a professional manner.
  • Display your photo ID at the start of the video when you introduce yourself.
  • Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).(Mental Health Soap Note Essay Example)
  • State 3–4 objectives for the presentation that are targeted, clear, use appropriate verbs from Bloom’s taxonomy, and address what the audience will know or be able to do after viewing.
  • Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
  • Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.(Mental Health Soap Note Essay Example)
  • Pose three questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.
  • Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide.
    • Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
    • Objective: What observations did you make during the psychiatric assessment?
    • Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms.(Mental Health Soap Note Essay Example)
    • Plan: What was your plan for psychotherapy (include one health promotion activity and patient education)? What was 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.  Discuss an identified social determinate of health impacting this patient’s mental health status and provide your recommendation for a referral to assist this patient in meeting this identified need (students will need to conduct research on this topic both in the literature and for community resources).
    • Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow-up, discuss what your next intervention would be.

A note on grading: 

  • Presenters: Review the Grand Rounds Presenter Rubric attached to this discussion to ensure you meet the scoring criteria.
  • Participants: Review the Grand Rounds Participant Rubric located on the following Week 4 Assignment 1 page to ensure you meet the scoring criteria. Note the Week 4 Assignment 1 page is for viewing the participant rubric only. Your response should be posted in the forum of this page.(Mental Health Soap Note Essay Example)

WEEK 4 PRESENTERS:

BY DAY 3

Post your video and your focused SOAP note to the Grand Rounds Discussion forum. You must submit two files for the SOAP note, including a Word document and scanned PDF/images of completed assignment signed by your Preceptor. Then, actively respond to and guide the conversation as your colleagues post responses to your video.(Mental Health Soap Note Essay Example)

WEEK 4 PARTICIPANTS:

BY MULTIPLE DAYS BETWEEN DAYS 4 AND 7

Respond at least 2 times each to all colleagues who presented this week (should be 2-3 presenters each week). The goal is for the discussion forum to function as robust clinical conferences on the patients. Provide a response to 1 of the 3 discussion prompts that your colleagues provided in their video presentations. You may also provide additional information, alternative points of view, research to support treatment, or patient education strategies you might use with the relevant patient.

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Mental Health Soap Note Essay Example

SOAP Note – Anxiety Disorder

The National Institute of Mental Health reports that among children and adolescents aged 13 to 18, anxiety disorder has a prevalence of 25.1%, and severe anxiety disorder has a lifetime prevalence of 5.9% (Wang et al., 2019). The trajectory of anxiety disorders in children often harms social, emotional, and academic functioning and development. This paper aims to assess and evaluate a pediatric patient with anxiety problems.(Mental Health Soap Note Essay Example)

Identifying Data:

Name: D.R.  DOB: November 29, 2007, Minor: Yes Age: 16 Years Gender: Male

SUBJECTIVE:

CC: “My mum advised me to see a psychiatrist.”

HPI: The patient, a 16-year-old African American male, presents at the clinic complaining of pervasive anxiety, irritability, and losing his temper easily. The patient’s mom advised him to see a psychiatrist. The patient reports having sleeping difficulties and struggling to develop and keep a relationship. The patient feels overly worried and sad. The patient reported to psychiatric evaluation to understand the problem and learn how to improve his quality of life by worrying less and being more composed and social.  (Mental Health Soap Note Essay Example)

Past Psychiatric History:

General statement: The patient has never had a psychiatric evaluation or diagnosis and is not receiving any psychiatric care or medication. The patient is seeing a psychiatrist for the first time.(Mental Health Soap Note Essay Example)

Caregiver: The mother is the caregiver.

            Hospitalization: Denied previous hospitalization

Medication trials: No previous medical trails

Psychotherapy or Previous Psychiatric Diagnosis: No previous psychiatric diagnosis

Substance Current Use: Denies using alcohol or tobacco. Reports smoking marijuana three times a day.

Medical History: Denies medical history.

  • Current Medications: Not under current medication.
  • Allergies:
  • Reproductive Hx:

Development Milestones:

Development milestones met on time

Health Promotion:

Vaccination up to date

Sleeps 3-5 hrs./night

Has proper nutrition per PCP.

Family Psychiatric/Substance Use History: The mother has a history of anxiety. The father is alive and well.

Psychosocial History: The patient was raised by his mother and lived with her. No history of sexual or physical abuse.   

ROS:  

General: Denies weight loss. Denies fever, chills, weakness, or fatigue.

HEENT: Eyes: denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.(Mental Health Soap Note Essay Example)

Skin: No rash or itching.

Cardiovascular: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.

Respiratory: Denies wheezes, shortness of breath, consistent coughs, and breathing difficulties while resting.

Gastrointestinal: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

Genitourinary: Denies burning on urination, urgency, hesitancy, odor, and odd color.

Neurological: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. Reports difficulties concentrating, paying attention, or staying still in class.  

Musculoskeletal: Denies muscle, back pain, joint pain, or stiffness.

Hematologic: Denies anemia, bleeding, or bruising.(Mental Health Soap Note Essay Example)

Lymphatics: Denies enlarged nodes. No history of splenectomy.(Mental Health Soap Note Essay Example)

Endocrinologic: Denies Sweating, No reports of cold or heat intolerance. No polyuria or polydipsia.

Psychiatric: Reports a worried and anxious mood, worrying every time and about everything.

OBJECTIVE:

Vital signs: Stable

Temp: 97.4F

            B.P.: 120/60

            P: 84

             R.R.: 18

             O2: Room air

             Pain: 0/10

             Ht: 5’8 feet

             Wt: 135 lbs

             BMI: 19.6

             BMI Range: Healthy weight

Physical Exam:

General appearance: The patient is alert and oriented to self, date, and place. The patient looks well-fed and in good health. His conversation and engagement with the interviewer are regular, and he responds well to the questions. The patient was fully attentive during the interview.(Mental Health Soap Note Essay Example)

HEENT: Normocephalic and atraumatic. Sclera anicteric, No conjunctival erythema, PERRLA, oropharynx red, moist mucous membranes.

Neck: Supple. No JVD. Trachea midline. No pain, swelling, or palpable nodules.

Heart/Peripheral Vascular: Regular rate and rhythm noted. No murmurs. No palpitation. No peripheral edema to palpation bilaterally.(Mental Health Soap Note Essay Example)

Cardiovascular: Although the patient’s heartbeat and rhythm are regular, murmurs and other sounds are coming from his chest. The patient’s heart rate is constant, and capillaries refill in two seconds.(Mental Health Soap Note Essay Example)

Musculoskeletal: Normal range of motion. Regular muscle mass for age. No signs of swelling or joint deformities.

Respiratory: No wheezes, and respirations are easy and regular.

Neurological: Balance is stable, gait is normal, posture is erect, tone is good, and speech is regular. His concentration and attention are impaired, and she struggles with school.(Mental Health Soap Note Essay Example)

Psychiatric: The patient has an anxious, worried, and sad mood. The patient indicates aggressive behavior.

Labs:

Toxicity: PositiveAnxiety Disorders Comprehensive Soap Note

Alcohol: Negative

Diagnostic Results:

Hamilton Anxiety Rating Scale (HAM-A):

A rating range of 0 = not present to 1 = mild, 2 = moderate, and 3 = severe is employed in the HAM-A to assess generalized anxiety symptoms (Baker et al., 2019). Aside from observing the patient’s behavior throughout the interview, questions were asked on the patient’s anxiety, tension, fears, insomnia, intellect, sad mood, somatic muscular and sensory symptoms, cardiovascular, respiratory, gastrointestinal, genitourinary, and autonomic symptoms. With a total score of 25, the level of anxiety was relatively high.(Mental Health Soap Note Essay Example)

ASSESSMENT:

Mental Status Examination:

The patient is a 16-year-old male presenting with a worried and sad mood. The patient is worried all the time and about everything. The patient was cooperative during the interview, answering questions appropriately. The patient was alert and oriented to self, date, and place. The patient denies self-harm or suicidal and homicidal ideation.(Mental Health Soap Note Essay Example)

Diagnostic Impression:

  1. 9. Anxiety Disorder (Confirmed Diagnosis)
  2. 9. Major Depressive Disorder
  3. 10 Substance Use Disorder(Mental Health Soap Note Essay Example)
  4. F41.9. Anxiety Disorder (Confirmed Diagnosis): The patient indicates signs of anxiety disorder. The patient is worried all the time and about everything. The patient has a sad mood. He has difficulties sleeping, experiences bad dreams, and sleeps with the lights on. The patient reports struggling to fall asleep and develop and maintain relationships. Fear is related to anxiety, which appears as a future-focused emotional state that involves a sophisticated cognitive, affective, physiological, and behavioral response system geared at preparing for upcoming events or situations that are viewed as threatening (Chand et al., 2022). Fear of losing control, fear of physical harm or death, fear of “going crazy,” fear of others’ disapproval, frightening thoughts, mental images, or memories, the perception of unreality or detachment, difficulty focusing, being distracted easily, narrowing of attention, hypervigilance for threat, poor memory, and difficulty speaking are some cognitive symptoms of an anxiety disorder (Bhatia & Goyal, 2019). Anxiety disorder is diagnosed when a person cannot control their worrying; the diagnosis was confirmed.(Mental Health Soap Note Essay Example)
  5. F932.9. Major Depressive Disorder: Apathy and ongoing sadness are characteristics of depression. The ability of the patient to do daily tasks is severely restricted by the sorrow, emptiness, irritation, and physical and psychological changes that define all depressive disorders. Depressed patients demonstrate noticeably lower excitement or interest in nearly all activities for most of the day, almost daily. According to the DMS-5 criteria, five of the symptoms listed below must be present to diagnose depression: difficulty sleeping, loss of interest or pleasure, feelings of inadequacy or helplessness, fatigue or erratic energy, difficulties concentrating or paying attention, fluctuations in appetite or weight, psychomotor issues, suicidality, and depressed mood (Chand et al., 2021). The patient reports a sad mood, struggling to fall or stay asleep. However, this diagnosis was refuted because the symptoms did not fit the DMS-5 criteria for MDD.
  6. F19.10 Substance Use Disorder: The patient reports signs of addiction and substance use disorder. He reports using or smoking marijuana three times a day, which is more than usual. Long-term exposure to substances and subsequent physical and mental dependence development lead to substance use disorders. It can harm one’s health and social, academic, and professional functioning. The DSM-5 is used to establish a diagnosis based on substance use. According to DSM-5, a person cannot be diagnosed with a drug use disorder for a substance unless they meet at least two of the 11 criteria for a year (Jahan & Burgess, 2021). The criteria are generally the same for all drugs. The eleven criteria include:
  7. More substance is consumed than was intended and consumed for longer than was intended.
  8. The aim to reduce use exists, as do the failed measures.(Mental Health Soap Note Essay Example)
  9. Obtaining, using, or recovering from the substance requires more time and effort.
  10. Having a great desire for the drug.(Mental Health Soap Note Essay Example)
  11. When a substance is used, it makes it impossible for the user to carry out their obligations.
  12. Usage of the substance notwithstanding social and professional impairment brought on by the use of the substance.
  13. Due to prolonged substance use, other activities are diminished or abandoned.
  1. Using the drug in a risky situation, such as driving a car or operating heavy machinery.
  2. Continued use of the substance despite being aware of its negative psychological and bodily repercussions.
  3. Tolerance can develop as a result of using more of a substance to get the same effect as before or as a result of using a substance at the same dose but getting less of an impact.
  4. After substance use is stopped, withdrawal symptoms appear; as long as substance use continues, the withdrawal symptoms subside.(Mental Health Soap Note Essay Example)

The patient does not indicate all these symptoms; hence the diagnosis was refuted. However, further evaluation is required to determine marijuana dependence and potential diagnosis of substance use disorder.

Case Formulation and Treatment Plan:

D.R. experiences pervasive worrying and reports a sad mood because the father left them and has never returned home. He struggles to sleep and has problems developing social relationships. He is also irritable and easily angered. This symptomology shows potential anxiety disorder. Combining pharmacological interventions, psychotherapy, and patient education is appropriate for this patient’s case.(Mental Health Soap Note Essay Example)

Pharmacological Intervention

Medication can treat anxiety problems in kids and teens, but it is not advised as a first-line treatment. To lessen the patient’s anxiety symptoms, a doctor may prescribe Zoloft at medium doses. 

Psychotherapy

Since medication is rarely advised, psychotherapy should be the primary line of treatment for anxiety disorders in children and adolescents. Behavioral psychotherapy is required to alleviate anxiety symptoms and improve executive function. Psychosocial therapies include applied relaxation interpersonal psychotherapy, short-term psychodynamic psychotherapy, and social skills instruction can assist in lessening the symptoms of anxiety. In addition to enhancing focus and attention, cognitive-behavioral treatment can assist in lessening excessive worrying, irritability, and getting angered easily (Chand et al., 2022). (Mental Health Soap Note Essay Example)

Patient Education

  • Educate the patient regarding medication risks and benefits, including non-treatment and probable side effects.
  • Discuss with the patient when to stop the medication, how to recognize it, and when to report adverse events.
  • Educate the patient on the dangers of combining prescription pharmaceuticals with other substances.
  • Educate the patient to develop structured daily routines and schedules and minimize changes.
  • Encourage the patient to engage in skills training(Mental Health Soap Note Essay Example).

Follow-up: The patient should follow up after one week.

Reflection:

The interview went well, and enough information was gathered to make a diagnosis and design a course of treatment. The patient cooperated and gave thoughtful answers to all of the questions. The patient displays symptoms of an anxiety illness. Children and adolescents who experience anxiety face challenges with functioning, academic achievement, social interactions, and self-care. The patient displays persistent fretting, anxiety, and melancholy. This encounter sheds light on how stress and anxiety affect adolescent behavior. If I had another chance to work with the patient, I would ask the teacher for more details to understand better the patient’s behavior, attitude, and academic achievement at school. Additionally, I would need the mother’s attendance. (Mental Health Soap Note Essay Example)

Working with adolescents is challenging. The patient is 16 and profoundly understands his health and body. He can provide insightful, reliable answers for the assessment. Still, the practitioner should obtain informed consent from the parent, promote patient autonomy, ensure no harm, maintain veracity, and treat the patient with dignity and respect. Every treatment decision should involve the parent despite the client being 16. It would be appropriate for the client to accompany the mother next time. Establishing patient trust requires maintaining objectivity and integrity, even when doing so can cause distress (Varkey, 2021). When discussing a patient’s medical information, the doctor must also protect their privacy, maintain confidentiality, and get their permission.(Mental Health Soap Note Essay Example)

The patient should promote his health by engaging in physical activities, developing work and study plans, and maintaining routines. Physical activities positively correlate with anxiety symptoms, helping patients manage their anxiety (Singh et al., 2023). Additionally, the patient has to reduce marijuana usage to prevent dependence. Marijuana usage can be a coping mechanism for excess anxiety and sadness. However, it is not advisable because the patient already uses it more than recommended.(Mental Health Soap Note Essay Example)

Mental Health Soap Note Essay Example

References

Baker, A., Simon, N., Keshaviah, A., Farabaugh, A., Deckersbach, T., Worthington, J. J., Hoge, E., Fava, M., & Pollack, M. P. (2019). Anxiety Symptoms Questionnaire (ASQ): development and validation. General psychiatry32(6), e100144. https://doi.org/10.1136/gpsych-2019-100144

Bhatia, M. S., & Goyal, A. (2019). Anxiety disorders in children and adolescents: Need for early detection. Journal of postgraduate medicine64(2), 75–76. https://doi.org/10.4103/jpgm.JPGM_65_18

Chand, S. P., Arif, H., & Kutlenios, R. M. (2021). Depression (Nursing). In: StatPearls [Internet]. StatPearls Publishing.

Chand, S. P., Marwaha, R., & Bender, R. M. (2022). Anxiety (nursing). In StatPearls [Internet]. StatPearls Publishing.

Jahan, A. R., & Burgess, D. M. (2021). Substance Use Disorder. In StatPearls [Internet]. StatPearls Publishing.

Singh, B., Olds, T., Curtis, R., Dumuid, D., Virgara, R., Watson, A., Szeto, K., O’Connor, E., Ferguson, T., Eglitis, E., Miatke, A., Simpson, C. E., & Maher, C. (2023). Effectiveness of physical activity interventions for improving depression, anxiety, and distress: An overview of systematic reviews. British Journal of Sports Medicine, by sports-2022-106195. https://doi.org/10.1136/bjsports-2022-106195

Varkey B. (2021). Principles of Clinical Ethics and Their Application to Practice. Medical Principles and Practice: international journal of the Kuwait University, Health Science Centre30(1), 17–28. https://doi.org/10.1159/000509119

Wang, Z., Whiteside, S., & Sim, L. (2019). Anxiety in Children. Rockville (M.D.): Agency for Healthcare Research and Quality (U.S.). https://www.ncbi.nlm.nih.gov/books/NBK476265/

Frequently Asked Questions

How do you write a mental health SOAP note?

To write a mental health SOAP note, begin with the Subjective section, where you document the patient’s reported symptoms, feelings, and experiences. Follow this with the Objective section, noting your observations and measurable findings. Then, detail your Assessment of the patient’s mental state, diagnosis, and treatment plan, and conclude with the Plan section outlining interventions, therapies, and follow-up steps.(Mental Health Soap Note Essay Example)

What is a mental health focused SOAP note?

A mental health focused SOAP note is a structured documentation method used by healthcare professionals to record subjective and objective observations, assessments, plans, and interventions related to a patient’s mental health condition during a clinical encounter. It helps organize and communicate essential information for effective diagnosis and treatment.(Mental Health Soap Note Essay Example)

What is the SOAP note format for psychiatry?

The SOAP note format for psychiatry is a structured method of documenting patient encounters. It includes four sections: Subjective (patient’s verbal information), Objective (clinician’s observations), Assessment (diagnosis and clinical impressions), and Plan (treatment plan and follow-up recommendations).(Mental Health Soap Note Essay Example)

What is a mental health note?

A mental health note is a document typically created by mental health professionals, such as therapists or psychiatrists, summarizing a client’s or patient’s session, including discussions, assessments, treatment plans, and progress made during therapy or treatment. These notes serve as a confidential record to aid in providing effective and consistent mental health care.(Mental Health Soap Note Essay Example)

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