week -4 case study soap note

Weel-4 Soap note

Assignment Details ( you can also use your imagination in addition to given information below, if specific information is not given)

Jill is a 50-year-old woman who lives with her husband and two children (aged 20 and 18). She has come to see her PMHNP with worries about a number of health problems including extreme tiredness, agitation and pains in her chest. Past history Jill has been a frequent attender at the practice over the years, often with concerns about her or her children’s health. She experienced postpartum depression with her second child. She has a history of GAD and Depression and has been on and off antidepressants for the past 30 years. When she was 23 she took an overdose following the break-up of a relationship. She had some sessions of counseling about 10 years ago that she found helpful. She was referred to a primary care mental health worker in the practice 2 years ago for help with anxiety and low mood. She had some sessions of individual guided self-help, but she found that this made no difference. She was put in touch with a voluntary sector self-help group for people with anxiety around this time – but did not pursue this. She has no other health history or complaints today related to medical health, no military history. She currently takes no medications and has no allergies. She considers herself healthy as she eats a vegan diet and does walk 2 times a week around the local lake.

On examination Jill says she has always been a very ‘nervy’ person who finds dealing with everyday stresses difficult. She worries a lot about herself and her family and easily gets ‘in a state’ and assumes ‘the worst’ – for example, if family members are unwell or if they are late coming home. Sometimes things get so bad that she needs someone around her constantly to reassure her and feels that she can’t be left on her own. The intensity of these problems has varied over the years, but has become worse again during the past 8 months following her husband’s diagnosis of heart problems. She has been drinking wine most evenings to try to calm herself down. More recently things have become so bad that she has sometimes felt that if she were left on her own she might harm herself. Her family has been very supportive and stayed with her during these periods until she calmed down, but is now finding this difficult to manage. Last night she had an extended period of feeling like everyone would be better off without her. She describes a plan “to drink alcohol, take some of her husband’s pain medications, start her car in the garage and pass out.” She states the only thing that ever helps her is to walk and hum to herself and in the winter she sometimes knits.

 

Vitals:
BP: 122/68
HR: 74
R: 18
T: 97
O2: 99%
Pain: 2 on 0–10 scale

Wt.: 147

Ht.: 66”

Direction

Read the case study, complete an initial assessment soap note and develop a safety plan for Jill. Add a short narrative about educating the family and patient about safety of environment and coping strategies to help the patient through any times involving suicidal thoughts or thoughts of self-harm. Consider if she should be admitted for monitoring or scheduled for more frequent follow-ups, what type of psychotherapy modality would be helpful, et cetera.

Use the SOAP Note template located under Course Resources to complete the assignment.

Please write

·
Initial SOAP note ( SEE ARTACH TEMPLET FOR SOAP note)

·
develop a safety plan for Jill

·
provide education about safety and coping strategy include family member

·
Develop good safety plan for Jill

·
Develop follow- up plan including psychotherapy modality

·
Use at list 4-5 definite and 3-4 differential diagnosis

Please use at list 3 references

Initial Psychiatric SOAP Note Template

There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to develop your style of SOAP in the psychiatric practice setting.

Criteria

Clinical Notes

Informed Consent

Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and
(Will review additional consent during treatment plan discussion)

Subjective

Verify Patient
Name:
DOB:

Minor:
Accompanied by:

Demographic:

Gender Identifier Note:

CC:

HPI:

Pertinent history in record and from patient: X

During assessment: Patient describes their mood as X and indicated it has gotten worse in TIME.

Patient self-esteem appears fair, no reported feelings of excessive guilt,
no reported anhedonia, does not report sleep disturbance, does not report change in appetite, does not report libido disturbances, does not report change in energy,
no reported changes in concentration or memory.

Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. Patient does not report excessive fears, worries or panic attacks.
Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a characterological nature.

SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors.

Allergies: NKDFA.
(medication & food)

Past Medical Hx:
Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury.
Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C.
Surgical history no surgical history reported

If Minor obtain Developmental Hx: (most often from parents), in utero, birth and delivery hx, early childhood, school hx, behavior, etc…

Nutritional status (this is an important component to gauge how well the mind and body are being nourished for full function. Ex: lack of iodine create thyroid issues, thyroid issues creates metabolism issues which affects function of cognition, mood, etc…)

Past Psychiatric Hx:

Previous psychiatric diagnoses: none reported.

Describes stable course of illness.

Previous medication trials: none reported.

Safety concerns:

History of Violence
to Self: none reported

History of Violence t
o Others: none reported

Auditory Hallucinations:
Visual Hallucinations:

Mental health treatment history discussed:

History of outpatient treatment: not reported
Previous psychiatric hospitalizations: not reported
Prior substance abuse treatment: not reported

Trauma history: Client does not report history of trauma including abuse, domestic violence, witnessing disturbing events.

Substance Use: Client denies use or dependence on nicotine/tobacco products.

Client does not report abuse of or dependence on ETOH, and other illicit drugs.

Current Medications: No current medications.
(Contraceptives):
Supplements:

Past Psych Med Trials:

Family Medical Hx:

Family Psychiatric Hx:
Substance use
Suicides
Psychiatric diagnoses/hospitalization
Developmental diagnoses

Social History:
Occupational History: currently unemployed. Denies previous occupational hx
Military service History: Denies previous military hx.
Education history: completed HS and vocational certificate
Developmental History: no significant details reported.
(Childhood History)
Legal History: no reported/known legal issues, no reported/known conservator or guardian.
Spiritual/Cultural Considerations: none reported.

ROS:
Constitutional: No report of fever or weight loss.
Eyes: No report of acute vision changes or eye pain.
ENT: No report of hearing changes or difficulty swallowing.
Cardiac: No report of chest pain, edema or orthopnea.
Respiratory: Denies dyspnea, cough or wheeze.
GI: No report of abdominal pain.
GU: No report of dysuria or hematuria.
Musculoskeletal: No report of joint pain or swelling.
Skin: No report of rash, lesion, abrasions.
Neurologic: No report of seizures, blackout, numbness or focal weakness. Endocrine: No report of polyuria or polydipsia.
Hematologic: No report of blood clots or easy bleeding.
Allergy: No report of hives or allergic reaction.
Reproductive: No report of significant issues. (females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…)

Verify Patient: Name, Assigned 
identification number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo.

Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview.

HPI:

, Past Medical and Psychiatric History,

Current Medications, Previous Psych Med trials,

Allergies.

Social History, Family History.

Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…”

Objective

Vital Signs: Stable

Temp:
BP:
HR:
R:
O2:
Pain:
Ht:
Wt:
BMI:
BMI Range:

LABS:
Lab findings WNL
Tox screen: Negative
Alcohol: Negative
HCG: N/A

Physical Exam:
MSE:
Patient is cooperative and conversant, appears without acute distress, and fully oriented x 4. Patient is dressed appropriately for age and season. Psychomotor activity appears within normal.
Presents with appropriate eye contact, euthymic affect – full, even, congruent with reported mood of “x”. Speech: spontaneous, normal rate, appropriate volume/tone with no problems expressing self.
TC: no abnormal content elicited, denies suicidal ideation and denies homicidal ideation. Process appears linear, coherent, goal-directed.
Cognition appears grossly intact with appropriate attention span & concentration and average fund of knowledge.
Judgment appears fair . Insight appears fair

The patient is able to articulate needs, is motivated for compliance and adherence to medication regimen. Patient is willing and able to participate with treatment, disposition, and discharge planning.

Diagnostic testing:
· PHQ-9, psychiatric assessment

This is where the “facts” are located.

Vitals,

**Physical Exam (if performed, will not be performed every visit in every setting)

Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results.

Assessment

DSM5 Diagnosis: with ICD-10 codes

Dx: –
Dx: –
Dx: –

Patient has the ability/capacity appears to respond to psychiatric medications/psychotherapy and appears to understand the need for medications/psychotherapy and is willing to maintain adherent.
Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment.

Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along
with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment.

Informed Consent Ability

Plan

Inpatient:
Psychiatric. Admits to X as per HPI.
Estimated stay 3-5 days

Patient is found to be stable and has control of behavior. Patient likely poses a minimal risk to self and a minimal risk to others at this time.
Patient denies abnormal perceptions and does not appear to be responding to internal stimuli.

Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic:

· No changes to current medication, as listed in chart, at this time
· or…Zoloft is an excellent option for many women who experience any menstrual cycle complaints. I usually start at 50 mg and move to 100 week 6-8. f/u within 2 weeks initially then every 6-8 weeks.
· Psychotherapy referral for CBT
Education, including health promotion, maintenance, and psychosocial needs
· Importance of medication
· Discussed current tobacco use. NRT not indicated.
· Safety planning
· Discuss worsening sx and when to contact office or report to ED
Referrals: endocrinologist for diabetes
Follow-up, including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit 2 weeks

☒ > 50% time spent counseling/coordination of care.

Time spent in Psychotherapy 18 minutes

Visit lasted 55 minutes

Billing Codes for visit:
XX
XX
XX

____________________________________________
NAME, TITLE

Date: Click here to enter a date. Time: X

Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options and complimentary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment and include patient education.

NW_11/1/20