Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.
scenario
Today, a 22-year-old woman comes in for a check-up and medication management. Trichotillomania and Attention Deficit Hyperactivity Disorder (ADHD), primarily inattentive type, are the diagnoses. The patient is attentive and oriented x 4, calm and cooperative; speech is clear and coherent; well-groomed; thought process is logical and sequential; gait is normal; appearance is normal; hygiene and grooming are fair, and the patient is calm and cooperative. The patient preparing for GRE says her medications are working well and there are no side effects, that she can stay focused on studying, that she has been sleeping well, that she has a normal appetite, that she hasn’t had any anxiety or depression, that she feels stable, that she hasn’t gone to therapy, that she doesn’t pull her hair out, that she doesn’t use alcohol or drugs, that she works part-time and has enough time to study, and that she exercises 5-6 times a week. Prescriptions have been submitted to the pharmacy, and the patient will return in 6 weeks. Medications management: 20 MG Oral Capsule Amphetamine-Dextroamphetamine (Adderall XR) Extended Edition a 24-hour period Plan: Continue present meds and return to the clinic in 6 months.
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.
