focused soap note

ASSIGNMENT

Anxiety disorders provide a good opportunity to take a close look at the nature/nurture debate as well as the gene/environment interactions that influence the nervous system and neurochemistry. A significant part of most of Sigmund Freud’s theories, the concept of anxiety has been debated and discussed over many years in the psychiatric literature. While Freud’s theories focused on the “mind” and the unconscious, another way to look at anxiety is with Hans Selye’s concept of “fight or flight” in which the sympathetic nervous system activates a response to stress. As you explore anxiety disorders, you will notice that no two cases of anxiety are the same.

Obsessive-compulsive disorder is characterized by the presence of obsessive thoughts, which manifest as persistent thoughts, images, or even “urges.” The only way that the individual can disperse the anxiety of these persistent thoughts/images and urges is to perform a behavior (the compulsion). The compulsion could be checking things, counting, reciting a silent prayer, or repeating a number of phrases. The disorder becomes so pervasive that the person can spend a significant amount of time each day attending to the compulsion in order to relieve the anxiety caused by the obsession.

Although trauma and stressor-related disorders stem from exposure to a traumatic or stressful event, not all exposures to trauma or stress will result in a disorder. However, following these types of events, patients may report symptoms that interfere with their ability to function well in one or more areas of their life, such as flashbacks, nightmares, or intense psychological or physiological distress.

This week, you will explore evidence-based treatment methods for patients with anxiety, obsessive-compulsive, as well as trauma and stressor-related disorders.

FOCUSED SOAP NOTE FOR ANXIETY, PTSD, AND OCD

In assessing patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders, you will continue the practice of looking to understand chief symptomology in order to develop a diagnosis. With a differential diagnosis in mind, you can then move to a treatment and follow-up plan that may involve both psychopharmacologic and psychotherapeutic approaches. 

In this Assignment, you use a case study to develop a focused SOAP note based on evidence-based approaches. 

TO PREPARE

· Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing anxiety, obsessive compulsive, and trauma-related disorders.

· Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.

· Review the video, 
Case Study: Dev Cordoba. You will use this case as the basis of this Assignment. In this video

NRNP_6675_Week3_Assignment_Rubric

NRNP_6675_Week3_Assignment_Rubric

Criteria

Ratings

Pts

This criterion is linked to a Learning OutcomeCreate documentation in the Focused SOAP Note Template about your assigned patient.In the Subjective section, provide: • Chief complaint• History of present illness (HPI)• Past psychiatric history• Medication trials and current medications• Psychotherapy or previous psychiatric diagnosis• Pertinent substance use, family psychiatric/substance use, social, and medical history• Allergies• ROS

15 to >13.0 pts

Excellent 90%–100%

The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.

13 to >11.0 pts

Good 80%–89%

The response accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.

11 to >10.0 pts

Fair 70%–79%

The response describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis but is somewhat vague or contains minor innacuracies.

10 to >0 pts

Poor 0%–69%

The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Or the subjective documentation is missing.

15 pts

This criterion is linked to a Learning OutcomeIn the Objective section, provide:• 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

15 to >13.0 pts

Excellent 90%–100%

The response thoroughly and

[MUSIC PLAYING] DR. JENNY: Hi there. My name is Dr. Jenny. Can you tell me your
name and how old you are? DEV CORDOBA: My name is Dev,
and I am seven years old. DR. JENNY: Wonderful. Dev, can you tell me what
the month and the date is? And where are we right now? DEV CORDOBA: Today
is St. Patrick’s Day. It’s March 17th. DR. JENNY: Do you
know where we are? DEV CORDOBA: We’re
at the school. DR. JENNY: Good. Did your mom tell you why
you’re here today to see me? DEV CORDOBA: She
thought you were going to help me be better. DR. JENNY: Yes, I
am here to help you. Have you ever come to see
someone like me before, or talked to someone like
me before to help you with your mood? DEV CORDOBA: No, never. DR. JENNY: OK. Well, I would like
to start with getting to know you a little bit
better, if that’s OK. What do you like to do for
fun when you’re at home? DEV CORDOBA: Oh, I have a dog. His name is Sparky. We play policeman in my room. And I have LEGOs, and I could
build something if you want. DR. JENNY: I would love to see
what you build with your LEGOs. Maybe you can bring that
in for me next appointment. Who lives in your home? DEV CORDOBA: My mom and my
baby brother and Sparky. DR. JENNY: Do you help
your mom with your brother? DEV CORDOBA: No. His breath smells like
bad milk all the time. [CHUCKLES] And he
cries a lot, and my mom spends more time with him. DR. JENNY: So how do you
feel most of the time? Do you feel sad or
worried or mad or happy? DEV CORDOBA: Worried. DR. JENNY: What types of
things do you worry about? DEV CORDOBA: I don’t
know, just everything. I don’t know. DR. JENNY: OK. So your mom tells me you also
have a lot of bad dreams. Can you tell me a little
more about your bad dreams, like maybe what they’re
about, how many nights you might have them? DEV CORDOBA: I dream
a lot that I’m lost, that I can’t find my mom
or my little brother. They seem like they happen
almost every night, but maybe not some nights. DR. JENNY: Now that
must feel horrible. Have you ever been lost before
when maybe you weren’t asleep? DEV CORDOBA: Oh, no. No. And I don’t like the dark. My mom puts me in a night
light with the door open, so I know she’s really there. DR. JENNY: That seems like
that probably would help. Do you like to go to school? Or would you rather not go? DEV CORDOBA: I worry
about by mom and brother when I’m at school. All I can think about
is what they’re doing, and if they’re OK. And besides, nobody
likes me there. They call me Mr. Smelly. DR. JENNY: Well. That’s not nice at all. Why do you feel
they call you names? DEV CORDOBA: I don’t know. But my mom says it’s because
I won’t take my baths. [SIGHS] She tells
me to, and it– and I have night accidents. DR. JENNY: Oh, how does
that make you feel? DEV CORDOBA: Sad and really bad. They don’t know how it feels for
their daddy to never come home. What if my mom
doesn’t come home too? DR. JENNY: Yes, you seem
to worry about that a lot. Does this worry stop you from

NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar

INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY

If you are struggling with the format or remembering what to include, follow the
Focused SOAP Note Evaluation Template

AND
the Rubric
as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. After reviewing full details of the rubric, you can use it as a guide.

In the
Subjective section, provide:

· Chief complaint

· History of present illness (HPI)

· Past psychiatric history

· Medication trials and current medications

· Psychotherapy or previous psychiatric diagnosis

· Pertinent substance use, family psychiatric/substance use, social, and medical history

· Allergies

· ROS

Read rating descriptions to see the grading standards!

In the
Objective section, provide:

· 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.

Read rating descriptions to see the grading standards!

In the
Assessment section, provide:

· Results of the mental status examination,

presented in paragraph form.

· At least three differentials with supporting evidence. List them from top priority to least priority. Compare the
DSM-5-TR diagnostic criteria for each differential diagnosis and explain what
DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis.

Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case

.

·
Read rating descriptions to see the grading standards!

Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (


demonstrate critical thinking beyond confidentiality and consent for treatment

!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

(The FOCUSED SOAP psychiatric evaluation is typically the
follow-up visit patient note. You will practice writing this type of note in this course. You wi

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Subjective:

CC (chief complaint):

HPI:

Substance Current Use:

Medical History:

·
Current Medications:

·
Allergies:

·
Reproductive Hx:

ROS:

· GENERAL:

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:

Diagnostic Impression:

Reflections:

Case Formulation and Treatment Plan: 

References

© 2021 Walden University

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Required Media

· Centers for Disease Control and Prevention. (2020, April 3). 


Adverse childhood experiences (ACEs) Links to an external site.


 [Video].
 https://www.cdc.gov/violenceprevention/aces/index.html

· Dartmouth Films. (2018, September 25). 

Resilience  Links to an external site.
[Video]. YouTube.

· NCTSN. (2007). 


The promise of trauma-focused therapy for childhood sexual abuse

 Links to an external site.
 [Video].
https://www.nctsn.org/resources/promise-trauma-focused-therapy-childhood-sexual-abuse-video