Week 6 Discussion 1

Week 6 Discussion 1

Due: In an effort to facilitate scholarly discourse, create your initial post by Tuesday, and reply to at least two of your classmates, on two separate days, by Saturday.

Using the readings and references, write a complete SOAP note for this patient in the proper format.
It should include a subjective and objective section with correct patient information, an explanation of differential diagnoses, and a comprehensive treatment plan which incorporates both psychosocial interventions as well as a medication plan, if indicated, with collateral information and patient education.
Use appropriate scholarly references and APA format.
Use the SOAP note template found in the Week 6: Learning Materials for your submission.

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. Refer to the Psychiatric SOAP Note PowerPoint for further detail about each of these sections.

Criteria

Clinical Notes

Subjective

Include chief complaint, subjective information from the patient, names and relations of others present in the interview, and basic demographic information of the patient. HPI, Past Medical and Psychiatric History, Social History.

Objective

This is where the “facts” are located. Include relevant labs, test results, vitals, and Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…” Include MSE, risk assessment here, and psychiatric screening measure results.

Assessment

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.

Plan

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.

CG&AM&BF_10/10/18

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