SOAP NOTE Assignment: The client is 7 years old Hispanic male with history of GAD. The client came in with mom with current compliant of “I am having an off month”. The client had previously been a with ADD. Has struggled with retaining information. The client was diagnosed by his PCP and was prescribed Adderall but has not started taking it. Dad refused to give him any medication. Mom and dad separated in 2019. GAD: The client reports anxiety, “it never feels like I am doing the right thing”. Feels like he is doing the wrong thing all the time. Mom report client has been failing in class, got report from his schoolteachers that client is mostly anxious in class. The client report he sleeps off and on and appetite is good. The client meets the criteria for GAD, will start client on Lexapro 5 mg, to give 1/2 tablet for one week then start full dose going forward. Play therapy. The client has a 504 plan through the school. Will establish a sleep routine and sleep hygiene. SOAP NOTE Assignment
Safety: informed to call 9-1-1 when experiencing thoughts of hurting self or others. The client does not have a therapist. Will need to have a therapist for coping skills such as CBT. Will obtain baseline labs: CBC, CMP, Thyroid panel, VIT-D. Will follow up with client in two weeks. SOAP NOTE Assignment
Expectation.
- 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.
Specifically address the following for the patient, using your SOAP note as a guide: SOAP NOTE Assignment
- 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? SOAP NOTE Assignment
- 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 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. Also be sure to include at least one health promotion activity and one patient education strategy. SOAP NOTE Assignment
- 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.
RUBRIC
| · Discuss Subjective data:• Chief complaint• History of present illness (HPI)• Medications• Psychotherapy or previous psychiatric diagnosis• Pertinent histories and/or ROS | 9 (9%) – 10 (10%) The video accurately and concisely presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis. | 8 (8%) – 8 (8%) The video accurately presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis. | 7 (7%) – 7 (7%) The video presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis, but is somewhat vague or contains minor inaccuracies. | 0 (0%) – 6 (6%) The video presents an incomplete, inaccurate, or unnecessarily detailed/verbose description of the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis. Or subjective documentation is missing. |
| Discuss Objective data:• 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 | 9 (9%) – 10 (10%) The video accurately and concisely documents the patient’s physical exam for pertinent systems. Pertinent diagnostic tests and their results are documented, as applicable. | 8 (8%) – 8 (8%) The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are documented, as applicable. | 7 (7%) – 7 (7%) Documentation of the patient’s physical exam is somewhat vague or contains minor inaccuracies. Diagnostic tests and their results are documented but contain inaccuracies. | 0 (0%) – 6 (6%) The response provides incomplete, inaccurate, or unnecessarily detailed/verbose documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or objective documentation is missing. |
| Discuss results of Assessment:• Results of the mental status examination• Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms. | 18 (18%) – 20 (20%) The video accurately documents the results of the mental status exam. Video presents at least three differentials in order of priority for a differential diagnosis of the patient, and a rationale for their selection. Response justifies the primary diagnosis and how it aligns with DSM-5 criteria. | 16 (16%) – 17 (17%) The video adequately documents the results of the mental status exam. Video presents three differentials for the patient and a rationale for their selection. Response adequately justifies the primary diagnosis and how it aligns with DSM-5 criteria. | 14 (14%) – 15 (15%) The video presents the results of the mental status exam, with some vagueness or inaccuracy. Video presents three differentials for the patient and a rationale for their selection. Response somewhat vaguely justifies the primary diagnosis and how it aligns with DSM-5 criteria. | 0 (0%) – 13 (13%) The response provides an incomplete, inaccurate, or unnecessarily detailed/verbose description of the results of the mental status exam and explanation of the differential diagnoses. Or assessment documentation is missing. |
| Discuss treatment Plan:• A treatment plan for the patient that addresses psychotherapy; one health promotion activity and one patient education strategy; plan for treatment and management, including alternative therapies; pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters; and a rationale for the approaches selected. | 18 (18%) – 20 (20%) The video clearly and concisely outlines an evidence-based treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear and concise rationale for the treatment approaches recommended is provided. | 16 (16%) – 17 (17%) The video clearly outlines an appropriate treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear rationale for the treatment approaches recommended is provided. | 14 (14%) – 15 (15%) The response somewhat vaguely or inaccurately outlines a treatment plan for the patient and provides a rationale for the treatment approaches recommended. | 0 (0%) – 13 (13%) The response does not address the diagnosis or is missing elements of the treatment plan. |
| Reflect on this case. Discuss what you learned and what you might do differently. | 5 (5%) – 5 (5%) Reflections are thorough, thoughtful, and demonstrate critical thinking. | 4 (4%) – 4 (4%) Reflections demonstrate critical thinking. | 3.5 (3.5%) – 3.5 (3.5%) Reflections are somewhat general or do not demonstrate critical thinking. | 0 (0%) – 3 (3%) Reflections are incomplete, inaccurate, or missing. |
| Focused SOAP Note documentation | 18 (18%) – 20 (20%) The response clearly, accurately, and thoroughly follows the Focused SOAP Note format to document the selected patient case. | 16 (16%) – 17 (17%) The response accurately follows the Focused SOAP Note format to document the selected patient case. | 14 (14%) – 15 (15%) The response follows the Focused SOAP Note format to document the selected patient case, with some vagueness and inaccuracy. | 0 (0%) – 13 (13%) The response incompletely and inaccurately follows the Focused SOAP Note format to document the selected patient case. |
| Presentation style | 5 (5%) – 5 (5%) Presentation style is exceptionally clear, professional, and focused. | 4 (4%) – 4 (4%) Presentation style is clear, professional, and focused. | 3.5 (3.5%) – 3.5 (3.5%) Presentation style is mostly clear, professional, and focused | 0 (0%) – 3 (3%) Presentation style is unclear, unprofessional, and/or unfocused. |