Soap Note on Psychotherapy Treatment and DiagnosisT-SOAP NOTE Unit 10 Assignment – Clinical: SOAP Note
NU675-UNIT 10 ASSIGNMENT-SOAP NOTE
Every other 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.(Soap Note on Psychotherapy Treatment and Diagnosis for Nursing Students)
Rubric
NU674 Unit 14 Assignment – Clinical: SOAP Note (1)
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.(Soap Note on Psychotherapy Treatment and Diagnosis for Nursing Students)
0 pts
Level 0
Less than 50% of problems are listed; or main problem missed; or problems not prioritized and/or identified nonexistent problems.(Soap Note on Psychotherapy Treatment and Diagnosis 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(Soap Note on Psychotherapy Treatment and Diagnosis 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.(Soap Note on Psychotherapy Treatment and Diagnosis 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.(Soap Note on Psychotherapy Treatment and Diagnosis 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. NU675-UNIT 10 ASSIGNMENT-SOAP NOTE(Soap Note on Psychotherapy Treatment and Diagnosis 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%).(Soap Note on Psychotherapy Treatment and Diagnosis for Nursing Students)
0 pts
Level 0
Less than 50% of problems include appropriate counseling, monitoring, referral and/or follow-up plan.
2 pts
Total Points: 20
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Soap Note on Psychotherapy Treatment and Diagnosis for Nursing Students
Subjective:
CC (chief complaint): “My mother says I am losing my mind.”
ZC is a 14-year-old Asian-American male. ZC has been checked in for counselling in the mother’s company and is obsessed with the mood. Every night he has to stay outside for a long watching the mood. He believes the mood he lived on the moon in his “past life.” During the full moon, he takes longer hours than during other moon phases. “My mother thinks I am losing my mind, but I believe watching the moon is therapeutic. I wonder about those who live there. They must be beautiful and smart people like me.” ZC tends to be hungry at anyone who interrupts him, watching the mood. How obsession with the moon is getting worse. “Previously, he could ask me to take him out to watch the mood, and I even bought him binoculars. However, he has become so obsessed goes alone and remains outside for several hours”, says the mother. He prefers watching the mood than eating. Sometimes he does not bathe. He keeps mentioning that he will go to the moon when he dies. Since childhood, he has liked sticking out his tongue, twitching, and jerking his head. Sometimes he does not finish his homework and gets hungry when reminded about it. His performance is slowly declining, and he has concentration difficulties in class. During breaks, he secludes himself and sits watching the sky. He was diagnosed with major depressive following his father’s death in a road accident two years ago. Diagnosed with tic disorder aged five years.(Soap Note on Psychotherapy Treatment and Diagnosis for Nursing Students)
HPI: Past Psychiatric History:
Hospitalizations: Hospitalized for a common cold four years ago.
Medication trials: None.
Psychotherapy or Previous Psychiatric Diagnosis: Diagnosed with MDD 2 years ago and tic disorder five years ago.
Psychosocial History:
Substance Current Use and History: None.
Family Psychiatric/Substance Use History: Father abused alcohol.
Social History: Has two siblings, an older brother and a younger sister.
Home Environment: Live with the mother and two siblings.
Educational Level: Grade 9.
Hobbies: Watching earth documentaries.
Legal history: None.
Lifestyle: Sleeps 4-5 hours. Poor eating habits.
Medical History:
Current Medications: Pimozide 2 mg PO qDay to manage tics.
Allergies: None
Reproductive Hx: Not sexually active.
ROS
GENERAL: No fever or chills. 2lbs weight loss in the last two months.
HEENT:
Head: No headache.
Eyes: No visual changes
Ears/Nose/Throat: No hearing loss. No nasal congestion. No sore throat.
ENDOCRINOLOGIC: Reports decreased appetite. No cold/heat intolereance.
CARDIOVASCULAR: No history of syncope. No palpitations, chest pain, or palpitations.
GASTROINTESTINAL: No abdominal pain, nausea, or vomiting.
GENITOURINARY: No urination hesitance. No polyuria or dysuria.
LYMPHATICS: No bruising or petechiae.
INTEGUMENTARY: No dryness or rash.
NEUROLOGICAL: No numbness, weakness, or tremor.
MUSCULOSKELETAL: No joint, muscle, or back pain.
PSYCHOLOGICAL: Anxious and depressed.
RESPIRATORY: No breath pain, cough, wheeze, or sputum production.
Objective:
Vital Signs: BP: 97/68, HR: 83, R: 21 O2: 98, Pain: None, Ht:4’0′ Wt: 55 lbs BMI: 16.8 kg/m2 (32%, Healthy weight)
Diagnostic results:
Beck Depression Inventory (BDI): 45
Moods and Feelings Questionnaire for Suicidal Ideation (MFQ-SI): 25
Assessment:
Mental Status Examination: The patient is alert and oriented in all spheres. He is well groomed. Appears to be in no acute psychological distress. He is calm, with warm behaviour and comments. Makes good eye contact. Has a normal and expansive emotional range. Affect is congruent with the stated mood of “sadness.” Poor insight and judgment. Normal cognition, and memory, with difficulty in abstract thought. Denies active thought of wanting to harm himself or others. The patient shows no immediate risk to himself or others.(Soap Note on Psychotherapy Treatment and Diagnosis for Nursing Students)
Differential Diagnoses:
- Obsessive-Compulsive Disorder (OCD), 300.3 (F42). The patient’s symptoms suggest OCD with absent delusional beliefs as the primary diagnosis. The essential clinical features of OCD include compulsions or obsessions characterized by persistent thoughts and the inability to ignore these thoughts (American Psychological Association [APA], 2019). Individuals are driven to perform repetitive behaviours to prevent anxiety or reduce distress. The obsessions are time-consuming and are associated with significant impairment of other areas of functioning. Such symptoms must not be explained by other mental disorders or substance abuse. Moreover, individuals with OCD tend to avoid people, places, or events that trigger the obsessions.(Soap Note on Psychotherapy Treatment and Diagnosis for Nursing Students)
- Persistent (Chronic) Motoror Vocal Tic Disorder, 307.22 (F95.1 ). The patient’s symptoms suggest a persistent tic disorder characterized by multiple/single vocal or motor tics (APA, 2019). Although the tics may wax and wane, a persistent tic disorder should be experienced for more than one year and diagnosed before 18 years. Tic disturbances must not be attributed to other mental health conditions or substance abuse.(Soap Note on Psychotherapy Treatment and Diagnosis for Nursing Students)
- Major Depressive Disorder (MDD), moderate recurrent episode 296.32 (F33.1). The patient’s symptoms suggest MDD is characterized by loss of pleasure or depressed mood (APA, 2019). Individuals with MDD experience a depressed mood most of the day with marked diminished pleasure in doing routine activities. Other significant clinical features include insomnia, thoughts of death, inability to concentrate, worthlessness, and psychomotor agitation. These symptoms are associated with clinically significant distress and impairment in functioning areas. Such symptoms must not be attributed to other medical conditions or substance abuse.(Soap Note on Psychotherapy Treatment and Diagnosis for Nursing Students)
Reflections
The patient’s symptoms strongly suggest OCD, primarily characterized by obsessions and recurrent performance of specific activities and presented in the history of the present illness. Tic disorders and MDD are comorbid conditions in this case, and further investigations are necessary to determine the association between the conditions. Given this case scenario, I would have a session with the patient in the mother’s absence to create an environment for free expression from the patient. The ethical considerations, in this case, include informed consent, confidentiality, and autonomy. Written and informed consent is necessary for any intervention, as patients have the right to refuse treatment (Jonnalagadda, 2021). Patient information should be handled equally to uphold patient data privacy and autonomy.(Soap Note on Psychotherapy Treatment and Diagnosis for Nursing Students)
Treatment Plan
Pharmacological Interventions: Start sertraline 50 mg PO QID. 25-250 mg of sertraline per day is effective for OCD and MDD (Tini et al., 2022). Sertraline is well tolerated with a positive response in continued treatment. (Soap Note on Psychotherapy Treatment and Diagnosis for Nursing Students)
Non-Pharmacological Interventions: Start family cognitive-behavioural therapy (CBT). CBT solved behavioural and cognitive distortions from the presenting condition (Avasthi et al., 2019).(Soap Note on Psychotherapy Treatment and Diagnosis for Nursing Students)
Education: Discuss with the client and the mother the side effects of medication. Provide the client with the relevant emergency call lines:(Soap Note on Psychotherapy Treatment and Diagnosis for Nursing Students)
Referral: Psychologist for CBT.
Follow-up: After two weeks.
References
American Psychiatric Association. (2019). Diagnostic and statistical manual of mental disorders (7th ed.). American Psychiatric Publishing, Inc. (Soap Note on Psychotherapy Treatment and Diagnosis for Nursing Students)
Avasthi, A., Sharma, A., & Grover, S. (2019). Clinical practice guidelines for the management of obsessive-compulsive disorder in children and adolescents. Indian Journal of Psychiatry, 61(Suppl 2), 306. https://doi.org/10.4103%2Fpsychiatry.IndianJPsychiatry_554_18
Jonnalagadda, V. R. (2021). Ethical Considerations in Substance Use Disorders Treatment. Psychiatric Clinics, 44(4), 579-589. https://doi.org/10.1016/j.psc.2021.08.009
Tini, E., Smigielski, L., Romanos, M., Wewetzer, C., Karwautz, A., Reitzle, K., … & Walitza, S. (2022). Therapeutic drug monitoring of sertraline in children and adolescents: A naturalistic study with insights into the clinical response and treatment of obsessive-compulsive disorder. Comprehensive Psychiatry, 115, 152301. https://doi.org/10.1016/j.comppsych.2022.152301
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