Across the Lifespan Practicum SOAP
Provide 4 child/adolescent and 4 adult/geriatric SOAP notes. Diagnoses: Bipolar Disorder, Anxiety, Depression, Impulse Control, ADHD Practice Management, Diagnosis, and Procedures. Bipolar disorder, anxiety, depression, and attention deficit hyperactivity disorder (ADHD) are all common mental health conditions that can significantly impact a person’s quality of life and functioning.
Bipolar disorder is a mood disorder characterized by extreme shifts in mood, energy, and activity levels. These shifts can range from periods of elevated mood (called mania) to periods of low mood (called depression). People with bipolar disorder may also experience periods of stable mood in between these extreme mood states.
Anxiety is a normal emotion that everyone experiences from time to time, but when it becomes chronic and affects a person’s daily life, it may be diagnosed as an anxiety disorder. Anxiety disorders can take many forms, such as generalized anxiety disorder, panic disorder, phobias, and social anxiety disorder.
Depression is a mood disorder characterized by persistent feelings of sadness, hopelessness, and a lack of interest or pleasure in activities. It can also cause physical symptoms such as fatigue, changes in appetite and sleep patterns, and difficulty concentrating.
ADHD is a neurodevelopmental disorder that affects a person’s ability to pay attention, control impulsive behaviors, and regulate their activity level. It is often diagnosed in childhood, but it can also affect adults.
In terms of practice management, it is important for healthcare professionals to have a thorough understanding of these conditions and be able to accurately diagnose them in order to provide appropriate treatment and support to their patients. This may involve a combination of medication, therapy, and other interventions, depending on the specific needs of the patient. It is also important for healthcare professionals to be aware of the potential comorbidities (co-occurring conditions) that may be present in patients with these conditions, as this can influence treatment planning and prognosis. Also, enter a brief summary/synopsis of the patient’s visit into the note section. Include: Chief Complaint, Review of Systems, Mental Status Exam, and Plan.
Provide 4 child/adolescent and 4 adult/geriatric SOAP notes. You can make up the patients and their diagnosis.
Please don’t forget to enter the following into patient logs Date, Course, Clinical Instructor, Preceptor, Patient number, Client information, Visit information, Practice Management, Diagnosis, and Procedures. Also, enter a brief summary/synopsis of the patient’s visit into the note section.
EXAMPLE
CC: “ My depression is improving”
HPI: This is a 30 Y/O female who presents to the clinic for medication follow-up. She reports she is doing well on Lexapro 5 mg daily. She denies depression symptoms, anxiety, irritability, and mood swings. She is sleeping 8 hours at night. Her appetite is stable. She denies SI, HI, and AVH. She denies drug and alcohol use. She denies any major stressors.
ROS unremarkable, vitals stable
MSE: She is alert oriented x 4, Mood and Affect euthymic and congruent, judgment/insight fair, well dressed, and appears stated age. No evidence of psychosis appears to be in good physical health.
Plan: Continue Lexapro 5 mg daily, and obtain a full panel of labs including CBC, CMP, TSH, A1C, and Lipid as it is time for the patient’s annual labs and none are in the chart at this time.
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 Assessment 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 the full details of the rubric, you can use it as a guide.
In the Subjective section, provide:
• Chief complaint- this is the reason why the patient is at the clinic/hospital for THIS visit. “I was started on Sertraline 4 months ago but I don’t feel any changes with my depression.”
• History of present illness (HPI) – Characteristics of the symptoms or complaint; Course or how long symptoms have been present; Any triggers, precursors, or aggravators; any other symptoms noted (anxiety, lack of motivation, decreased energy/fatigue); Any treatments or alleviating factors noted; Client’s thoughts or any other pertinent information for that supports this visit.
• Past medical history – include prior surgeries, illness, injuries
• Past psychiatric history – including inpatient and outpatient psychiatric treatment and medications with the reason for discontinuation
• Medication trials and current medications – include psychotropic meds and non-psychotropic meds
• Family history
• Social history – born or raised, occupation or schooling/grade, marital status/children, nicotine/caffeine/alcohol or drug use, legal issues (incarcerated), physical activity, religion, and any trauma (physical, emotional or sexual)
• Pertinent substance use, family psychiatric/substance use, social, and medical history – nicotine/caffeine/alcohol or drug use, legal issues (incarcerated), physical activity, religion, and any trauma (physical, emotional, or sexual)
• Allergies
• ROS (Review of Systems)
o General
o HEENT
o Skin
o Cardiovascular
o Respiratory
o Gastrointestinal
o Genitourinary
o Neurological
o Musculoskeletal
o Hematologic
o Lymphatics
o Endocrinologic
o Reproductive (including last menstrual period or pregnancy)
In the Objective section, provide:
• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
o Mental Status Exam/Observation
Assess Suicidal Ideations, Homicidal Ideations, Psychotic Symptoms
Appearance
Orientation – person, place, time, situation
Dress/Grooming
Eye contact
Attitude
Motor
Speech
Mood
Affect
Thought Production
Thought Process – logical, linear, goal-directed, tangential, circumstantial, loose)
Thought content/perceptions – hallucinations, ideas of reference, paranoia, delusions, obsessions/compulsions)
Insight
Judgment
Intellect
Memory – include immediate, recent, and remote
Concentration
Attention
• Diagnostic results, including any labs (Chemistries, CBC, Thyroid studies, etc.) imaging, or other assessments needed to develop the differential diagnoses (including screening instruments – PHQ, PCL, Beck, etc.). Screening tools are a great process for measured base care (how well is the patient progressing with the current treatment plan)
In the Assessment section, provide:
• Results of the mental status examination, presented in paragraph form.
• Diagnosis/Diagnoses – include all mental health diagnoses and the ICD-10 codes for each. Be Specific with diagnosis. Example: Major depressive disorder, recurrent, moderate F33.1; General anxiety disorder F41.1
• At least three differentials with supporting evidence. List them from top priority to least priority.
Example:
Diagnosis: Major Depressive Disorder, Recurrent, Mild F33.0(per DSM-V)
Differential Diagnosis for Major Depressive Disorder:
• Mood disorder due to another medical condition
• Bipolar disorder, depressive type
• Attention-deficit/hyperactivity disorder
• Adjustment disorder with depressed mood
The differential diagnoses can be found in your DSM-V book, located in each section for the diagnosis.
In the Plan section, provide:
• All medications ordered including dose, route, time and number dispensed, and number of refills
• All non-pharmacological treatment including psychotherapy (individual, family, group), medical Assessments, special programs – recovery/addiction
• Referrals/Consults – community, medical
• Collaboration with the multidisciplinary team
• Specific labs and diagnostic tests ordered/pending
• Follow-up plan with timeline – Return to clinic in 2 months on October 9, 2022 @ 10 am
• Patient teaching – includes diagnosis, medication, treatment, emergency procedures, suicide hotlines, etc.
Reflect:
Discuss what you learned and what you might do differently. Include a brief rationale for your treatment plan. You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differential diagnoses and treatment plan. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rule out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. (Hint: the documentation in subjective and objective should support your diagnosis according to DSM-V!) 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.).
Reference Page:
You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differential diagnoses as well as the treatment plan. Be sure to use correct APA 7th edition formatting. Do NOT submit actual journal articles with your SOAP note. You only have to submit a reference page with your SOAP note. Cite references in the Reflect section only.
