Assignment 2: FocusedSOAP Note and Patient Case PresentationSchizophrenia
Psychiatric notes are a wayto reflect on your practicum experiences and connect the experiences to thelearning you gain from your weekly Learning Resources. Focused SOAP notes, suchas the ones required in this practicum course, are often used in clinicalsettings to document patient care.For thisAssignment, you will document information about a patient that you examinedduring the last 4 weeks, using the Focused SOAP Note Template provided. Youwill then use this note to develop and record a case presentation for thispatient.Select an adultpatient that you examined during the last 4 weeks who presentedwith a disorder other than the disorder present in your Week 3Case Presentation. (Disorder selected is Schizophrenia)Create a Focused SOAP Noteon this patient using the template provided in the Learning Resources.There is also a completed Focused SOAP Note Exemplar provided to serve asa guide to assignment expectations.
Include at least fivescholarly resources to support your assessment, diagnosis, and treatmentplanning.
Present the full complexcase study. Include chief complaint; history of present illness; anypertinent past psychiatric, substance use, medical, social, familyhistory; most recent mental status exam; current psychiatric diagnosisincluding differentials that were ruled out; and plan for treatment andmanagement.Report normal diagnosticresults as the name of the test and “normal” (rather than specific value).Abnormal results should be reported as a specific value.
Subjective: What details did thepatient provide regarding their chief complaint and symptomology toderive your differential diagnosis? What is the duration and severity oftheir symptoms? How are their symptoms impacting their functioning inlife?Objective: What observations did youmake during the psychiatric assessment?Assessment: Discuss patientmental 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 primarydiagnosis, and why? Describe how your primary diagnosis alignswith DSM-5 diagnostic criteria and supported by thepatient’s symptoms.Plan: What was your planfor psychotherapy? What was your plan for treatment and management,including alternative therapies? Include pharmacologic andnonpharmacologic treatments, alternative therapies, and follow-upparameters, as well as a rationale for this treatment and managementplan. Be sure to include at least one health promotion activity andone patient education strategy.Reflection notes: What would you dodifferently with this patient if you could conduct the sessionover? If you are able to follow up with your patient, explainwhether these interventions were successful and why or why not. If youwere not able to conduct a follow up, discuss what your next interventionwould be.
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