Wk7 SOAP NOTE
The consumer is 24 years outdated with a historic previous of Bipolar, acquired right here in for her routine go to. She opinions racing concepts, elevated emotionality, and concern staying on course of. She opinions sleep is good and good appetites. The consumer is in the meanwhile on Lithium 900 mg every day, Abilify 2.5mg, was tapered off Quetiapine. Will start Clonidine zero.5 mg every day to help with focus, enhance Abilify to 5mg every day and proceed 900mg lithium every day. The consumer states she has scheduled two courses. Refills despatched to the affected individual pharmacy. Will see affected individual in two three weeks.
Expectation. Use the detailed Rubric on the end of this doc.
• Present the full superior case study. Embrace chief grievance; historic previous of present illness; any pertinent earlier psychiatric, substance use, medical, social, family historic previous; most recent psychological standing examination; current psychiatric prognosis along with differentials that had been dominated out; and plan for remedy and administration.
• Report common diagnostic outcomes as a result of the title of the examine and “common” (pretty than explicit price). Irregular outcomes should be reported as a specific price.
Significantly cope with the subsequent for the affected individual, using your SOAP remember as a info:
• Subjective: What particulars did the affected individual current regarding their chief grievance and symptomology to derive your differential prognosis? What is the interval and severity of their indicators? How are their indicators impacting their functioning in life?
• Aim: What observations did you make via the psychiatric analysis?
• Analysis: Speak about their psychological standing examination outcomes. What had been your differential diagnoses? Current a minimal of three potential diagnoses and why you chose them. Itemizing them from highest priority to lowest priority. What was your principal prognosis and why? Describe how your principal prognosis aligns with DSM-5 diagnostic requirements and supported by the affected individual’s indicators.
• Plan: What was your plan for psychotherapy? What was your plan for remedy and administration, along with varied therapies? Embrace pharmacologic and nonpharmacologic therapies, varied therapies, and follow-up parameters, along with a rationale for this remedy and administration plan. Moreover ensure you embrace as a minimum one effectively being promotion train and one affected individual coaching method.
• Reflection notes: What would you do in one other means with this affected individual ought to chances are you’ll conduct the session as soon as extra? If you’ll adjust to up collectively along with your affected individual, make clear whether or not or not these interventions had been worthwhile and why or why not. In case you weren’t able to conduct a adjust to up, deal with what your subsequent intervention could be.
RUBRIC
Detailed Rubric
Title: PRAC_6665_Week7_Assignment2_Rubric
• Itemizing View
Superb Good Truthful Poor
zero (zero%) – zero (zero%) zero (zero%) – zero (zero%)
Photograph ID simply is not displayed. Scholar ought to remedy this sooner than grade is posted. The scholar simply is not dressed professionally.
zero (zero%) – zero (zero%) zero (zero%) – zero (zero%)
The video exceeds the Eight-minute time limit. (Phrase: Data launched after Eight minutes will not be evaluated for grade inclusion.)
Speak about Subjective info:
• Chief grievance
• Historic previous of present illness (HPI)
• Medication
• Psychotherapy or earlier
psychiatric prognosis
• Pertinent histories and/or ROS 9 (9%) – 10 (10%)
The video exactly and concisely presents the affected individual’s subjective grievance, historic previous of present illness, medicines, psychotherapy or earlier psychiatric prognosis, and pertinent histories and/or overview of applications that can inform a differential prognosis. Eight (Eight%) – Eight (Eight%)
The video exactly presents the affected individual’s subjective grievance, historic previous of present illness, medicines, psychotherapy or earlier psychiatric prognosis, and pertinent histories and/or overview of applications that can inform a differential prognosis. 7 (7%) – 7 (7%)
The video presents the affected individual’s subjective grievance, historic previous of present illness, medicines, psychotherapy or earlier psychiatric prognosis, and pertinent histories and/or overview of applications that can inform a differential prognosis, nevertheless is significantly imprecise or includes minor inaccuracies. zero (zero%) – 6 (6%)
The video presents an incomplete, inaccurate, or unnecessarily detailed/verbose description of the affected individual’s subjective grievance, historic previous of present illness, medicines, psychotherapy or earlier psychiatric prognosis, and pertinent histories and/or overview of applications that can inform a differential prognosis. Or subjective documentation is missing.
Speak about Aim info:
• Bodily examination documentation of applications pertinent to the chief grievance, HPI, and historic previous
• Diagnostic outcomes, along with any labs, imaging, or completely different assessments needed to develop the differential diagnoses 9 (9%) – 10 (10%)
The video exactly and concisely paperwork the affected individual’s bodily examination for pertinent applications. Pertinent diagnostic exams and their outcomes are documented, as related. Eight (Eight%) – Eight (Eight%)
The response exactly paperwork the affected individual’s bodily examination for pertinent applications. Diagnostic exams and their outcomes are documented, as related. 7 (7%) – 7 (7%)
Documentation of the affected individual’s bodily examination is significantly imprecise or includes minor inaccuracies. Diagnostic exams and their outcomes are documented nevertheless embrace inaccuracies. zero (zero%) – 6 (6%)
The response offers incomplete, inaccurate, or unnecessarily detailed/verbose documentation of the affected individual’s bodily examination. Applications might have been unnecessarily reviewed, or aim documentation is missing.
Speak about outcomes of Analysis:
• Outcomes of the psychological standing examination
• Current a minimal of three potential diagnoses in order of highest to lowest priority and make clear why you chose them. What was your principal prognosis and why? Describe how your principal prognosis aligns with DSM-5 diagnostic requirements and is supported by the affected individual’s indicators. 18 (18%) – 20 (20%)
The video exactly paperwork the outcomes of the psychological standing examination.
Video presents as a minimum three differentials in order of priority for a differential prognosis of the affected individual, and a rationale for his or her alternative. Response justifies the primary prognosis and the way in which it aligns with DSM-5 requirements. 16 (16%) – 17 (17%)
The video adequately paperwork the outcomes of the psychological standing examination.
Video presents three differentials for the affected individual and a rationale for his or her alternative. Response adequately justifies the primary prognosis and the way in which it aligns with DSM-5 requirements. 14 (14%) – 15 (15%)
The video presents the outcomes of the psychological standing examination, with some vagueness or inaccuracy.
Video presents three differentials for the affected individual and a rationale for his or her alternative. Response significantly vaguely justifies the primary prognosis and the way in which it aligns with DSM-5 requirements. zero (zero%) – 13 (13%)
The response offers an incomplete, inaccurate, or unnecessarily detailed/verbose description of the outcomes of the psychological standing examination and clarification of the differential diagnoses. Or analysis documentation is missing.
Speak about remedy Plan:
• A remedy plan for the affected individual that addresses psychotherapy; one effectively being promotion train and one affected individual coaching method; plan for remedy and administration, along with varied therapies; pharmacologic and nonpharmacologic therapies, varied therapies, and follow-up parameters; and a rationale for the approaches chosen. 18 (18%) – 20 (20%)
The video clearly and concisely outlines an evidence-based remedy plan for the affected individual that addresses psychotherapy, effectively being promotion and affected individual coaching, remedy and administration, pharmacologic and nonpharmacologic therapies, varied therapies, and follow-up parameters. A clear and concise rationale for the remedy approaches actually helpful is provided. 16 (16%) – 17 (17%)
The video clearly outlines an relevant remedy plan for the affected individual that addresses psychotherapy, effectively being promotion and affected individual coaching, remedy and administration, pharmacologic and nonpharmacologic therapies, varied therapies, and follow-up parameters. A clear rationale for the remedy approaches actually helpful is provided. 14 (14%) – 15 (15%)
The response significantly vaguely or inaccurately outlines a remedy plan for the affected individual and provides a rationale for the remedy approaches actually helpful. zero (zero%) – 13 (13%)
The response does not cope with the prognosis or is missing components of the remedy plan.
Replicate on this case. Speak about what you found and what chances are you’ll do in one other means. 5 (5%) – 5 (5%)
Reflections are thorough, thoughtful, and reveal very important pondering. 4 (4%) – 4 (4%)
Reflections reveal very important pondering. three.5 (three.5%) – three.5 (three.5%)
Reflections are significantly widespread or do not reveal very important pondering. zero (zero%) – three (three%)
Reflections are incomplete, inaccurate, or missing.
Focused SOAP Phrase documentation 18 (18%) – 20 (20%)
The response clearly, exactly, and completely follows the Focused SOAP Phrase format to doc the chosen affected individual case. 16 (16%) – 17 (17%)
The response exactly follows the Focused SOAP Phrase format to doc the chosen affected individual case. 14 (14%) – 15 (15%)
The response follows the Focused SOAP Phrase format to doc the chosen affected individual case, with some vagueness and inaccuracy. zero (zero%) – 13 (13%)
The response incompletely and inaccurately follows the Focused SOAP Phrase format to doc the chosen affected individual case.
Presentation mannequin 5 (5%) – 5 (5%)
Presentation mannequin is exceptionally clear, expert, and focused. 4 (4%) – 4 (4%)
Presentation mannequin is clear, expert, and focused. three.5 (three.5%) – three.5 (three.5%)
Presentation mannequin is usually clear, expert, and focused zero (zero%) – three (three%)
Presentation mannequin is unclear, unprofessional, and/or unfocused.
Entire Components: 100
Title: PRAC_6665_Week7_Assignment2_Rubric
Assessment paper writing service
