Focused Note

  • Select an adult patient that you examined during the last 4 weeks who presented with a disorder other than the disorder present in your Week 3 Case Presentation.
  • Create a Focused SOAP Note on this patient using the template  provided in the Learning Resources. There is also a completed Focused  SOAP Note Exemplar provided to serve as a guide to assignment  expectations.

 

  • 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.
  • 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 patient 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 diagnostic criteria and supported by the patient’s symptoms.
  • Plan: What was your plan for psychotherapy? 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. Be sure to include at least one health  promotion activity and one patient education strategy.
  • Reflection notes: What would you do differently with this  patient if you could conduct the session over? 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.

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