PRAC – 6665 Week 7: Focused SOAP Note and Patient Case Presentation
What do I have to do? When do I have to do it?
Review your Learning Resources. Days 1–7
Assignment 1: Clinical Hour and Patient Logs Record your clinical hours and patient encounters in Meditrek by Day 7.
Assignment 2: Focused SOAP Note and Patient Case Presentation Submit by Day 7.
Introduction
Your weekly practicum Learning Resources support your knowledge of the assessment, diagnosis, and treatment of patients across the lifespan. It is recognized that at your site, you likely are seeing patients with a variety of mental health disorders and other comorbidities. Consult the DSM-5, clinical practice guidelines, and your textbooks from previous coursework, as needed, to support the experiences you are encountering at your site. If you encountered a patient at your practicum site with a neurocognitive or neurodevelopmental disorder, consider what patient factors and behaviors you think might impact the disorder. Also, consider how psychopharmacological and/or psychotherapy interventions may be appropriate for the patient. As you progress in your clinical practicum, you continue to use Meditrek to record your time and patient encounters, thoughtfully considering the skills you are gaining. You will also complete a second Focused SOAP Note and Patient Case Presentation.
Learning Objectives
Students will:
Describe clinical hours and patient encounters
Assess patients across the lifespan in mental health settings
Formulate differential diagnoses for patients across the lifespan in mental health settings
Develop plans of care for patients across the lifespan in mental health settings
Advocate health promotion and patient education strategies across the lifespan
Develop a case study presentation based on a clinical patient
Learning Resources
Required Readings
Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
Chapter 28, “Assessing Neurocognitive Disorders (Dementia and Delirium)”
Meditrek
https://edu.meditrek.com/Default.html
Note: Use this link to log into Meditrek to report your clinical hours and patient encounters.
Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Massachusetts General Hospital psychopharmacology and neurotherapeutics. Elsevier.
Chapter 10, “Stimulants and Other Meds for ADHD”
Chapter 13, “Natural Medications in Psychiatry” (pp. 147–148 only)
Chapter 14, “Dementia”
Document: Focused SOAP Note Template (Word document)
Document: Focused SOAP Note Exemplar (Word document)
Assignment 1: Clinical Hour and Patient Logs
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Clinical Hour Log
For this course, all practicum activity hours are logged within the Meditrek system. Hours completed must be logged in Meditrek within 48 hours of completion in order to be counted.
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You may only log hours with Preceptors that are approved in Meditrek. Students with catalog years before Spring 2018 must complete a minimum of 576 hours of supervised clinical experience (144 hours in each practicum course). Students with catalog years beginning Spring 2018 must complete a minimum of 640 hours of supervised clinical experience (160 hours in each practicum course). PRAC – 6665 Week 7: Focused SOAP Note and Patient Case Presentation
Each log entry must be linked with an individual practicum Learning Objective or a graduate Program Objective. You should track your hours in Meditrek as they are completed.
Your clinical hour log must include the following:
Dates
Course
Clinical Faculty
Preceptor
Total Time (for the day)
Notes/Comments (including the objective to which the log entry is aligned)
Patient Log
Throughout this course, you will also keep a log of patient encounters using Meditrek. You must record at least 80 encounters with patients by the end of this practicum (40 children/adolescents and 40 adult/older adult).
The patient log must include the following:
Date
Course
Clinical Faculty
Preceptor
Patient Number
Client Information
Visit Information
Practice Management
Diagnosis
Treatment Plan and Notes: You must include a brief summary/synopsis of the patient visit. This does not need to be a SOAP note, however the note needs to be sufficient to remember your patient encounter.
By Day 7 of Week 7
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You are required to complete Assignment 1: Clinical Hour and Patient Logs, which consists of recording your clinical hours and patient encounters in Meditrek by Day 7. You are also required to complete Assignment 2: Focused SOAP Note and Patient Case Presentation and submit it by Day 7. You should use the Meditrek system to log your clinical hours and patient encounters, and ensure that each log entry is linked with an individual practicum Learning Objective or a graduate Program Objective. Additionally, you are required to keep a log of patient encounters, with at least 80 encounters recorded by the end of the practicum (40 children/adolescents and 40 adult/older adult). The patient log must include the date, course, clinical faculty, preceptor, patient number, client information, visit information and practice management information.
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Record your clinical hours and patient encounters in Meditrek.
Assignment 2: Focused SOAP Note and Patient Case Presentation
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Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you examined during the last 4 weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.
To Prepare
Review the Kaltura Media Uploader resource for help creating your self-recorded Kaltura video
Select an adult patient that you examined during the last 4 weeks who presented with a disorder other than the disorder present in your Week 3 Case Presentation.
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. PRAC – 6665 Week 7: Focused SOAP Note and Patient Case Presentation
Please Note:
All SOAP notes must be signed, and each page must be initialed by your Preceptor.
Note: Electronic signatures are not accepted.
When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor.
You must submit your SOAP note using SafeAssign.
Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.
Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record.
Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
Ensure that you have the appropriate lighting and equipment to record the presentation.
The Assignment
Record yourself presenting the complex case study for your clinical patient. In your presentation:
Dress professionally with a lab coat and present yourself in a professional manner.
Display your photo ID at the start of the video when you introduce yourself.
Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide:
Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective: What observations did you make during the psychiatric assessment?
Assessment: Discuss patient mental 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 primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.
Plan: What was your plan for psychotherapy? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Be sure to include at least one health promotion activity and one patient education strategy.
Reflection notes: What would you do differently with this patient if you could conduct the session over? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.
By Day 7 of Week 7
Submit your Video and Focused SOAP Note Assignment. You must submit two files for the note, including a Word document and scanned PDF/images of each page that is initialed and signed by your Preceptor.
