Create a Focused SOAP Note on this patient using the template provided in the Learning Assets. There may be additionally a accomplished Focused SOAP Note Exemplar provided to function a information to project expectations.
situation
Immediately, a 22-year-old lady comes in for a check-up and drugs administration. Trichotillomania and Consideration Deficit Hyperactivity Dysfunction (ADHD), primarily inattentive kind, are the diagnoses. The patient is attentive and oriented x four, calm and cooperative; speech is evident and coherent; well-groomed; thought course of is logical and sequential; gait is regular; look is regular; hygiene and grooming are truthful, and the patient is calm and cooperative. The patient getting ready for GRE says her medicines are working nicely and there aren’t any uncomfortable side effects, that she will be able to keep targeted on finding out, that she has been sleeping nicely, that she has a regular urge for food, that she hasn’t had any nervousness or despair, that she feels steady, that she hasn’t gone to remedy, that she would not pull her hair out, that she would not use alcohol or medicine, that she works part-time and has sufficient time to check, and that she workout routines 5-6 occasions a week. Prescriptions have been submitted to the pharmacy, and the patient will return in 6 weeks. Drugs administration: 20 MG Oral Capsule Amphetamine-Dextroamphetamine (Adderall XR) Prolonged Version a 24-hour interval Plan: Proceed current meds and return to the clinic in 6 months.
Chief criticism
• Historical past of current sickness (HPI)
• Drugs
• Psychotherapy or earlier
psychiatric analysis
• Pertinent histories and/or ROS
9 (9%) – 10 (10%)
The video precisely and concisely presents the patient’s subjective criticism, historical past of current sickness, medicines, psychotherapy or earlier psychiatric analysis, and pertinent histories and/or overview of techniques that may inform a differential analysis. eight (eight%) – eight (eight%)
The video precisely presents the patient’s subjective criticism, historical past of current sickness, medicines, psychotherapy or earlier psychiatric analysis, and pertinent histories and/or overview of techniques that may inform a differential analysis. 7 (7%) – 7 (7%)
The video presents the patient’s subjective criticism, historical past of current sickness, medicines, psychotherapy or earlier psychiatric analysis, and pertinent histories and/or overview of techniques that may inform a differential analysis, however is considerably imprecise or accommodates minor inaccuracies. zero (zero%) – 6 (6%)
The video presents an incomplete, inaccurate, or unnecessarily detailed/verbose description of the patient’s subjective criticism, historical past of current sickness, medicines, psychotherapy or earlier psychiatric analysis, and pertinent histories and/or overview of techniques that may inform a differential analysis. Or subjective documentation is lacking.
Focus on Goal knowledge:
• Bodily examination documentation of techniques pertinent to the chief criticism, HPI, and historical past
• Diagnostic outcomes, together with any labs, imaging, or different assessments wanted to develop the differential diagnoses 9 (9%) – 10 (10%)
The video precisely and concisely paperwork the patient’s bodily examination for pertinent techniques. Pertinent diagnostic checks and their outcomes are documented, as relevant. eight (eight%) – eight (eight%)
The response precisely paperwork the patient’s bodily examination for pertinent techniques. Diagnostic checks and their outcomes are documented, as relevant. 7 (7%) – 7 (7%)
Documentation of the patient’s bodily examination is considerably imprecise or accommodates minor inaccuracies. Diagnostic checks and their outcomes are documented however include inaccuracies. zero (zero%) – 6 (6%)
The response offers incomplete, inaccurate, or unnecessarily detailed/verbose documentation of the patient’s bodily examination. Programs might have been unnecessarily reviewed, or goal documentation is lacking.
Focus on outcomes of Assessment:
• Outcomes of the psychological standing examination
• Present a minimal of three potential diagnoses in order of highest to lowest precedence and clarify why you selected them. What was your major analysis and why? Describe how your major analysis aligns with DSM-5 diagnostic standards and is supported by the patient’s signs. 18 (18%) – 20 (20%)
The video precisely paperwork the outcomes of the psychological standing examination.
Video presents at the least three differentials in order of precedence for a differential analysis of the patient, and a rationale for his or her choice. Response justifies the major analysis and the way it aligns with DSM-5 standards. 16 (16%) – 17 (17%)
The video adequately paperwork the outcomes of the psychological standing examination.
Video presents three differentials for the patient and a rationale for his or her choice. Response adequately justifies the major analysis and the way it aligns with DSM-5 standards. 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 patient and a rationale for his or her choice. Response considerably vaguely justifies the major analysis and the way it aligns with DSM-5 standards. zero (zero%) – 13 (13%)
The response offers an incomplete, inaccurate, or unnecessarily detailed/verbose description of the outcomes of the psychological standing examination and rationalization of the differential diagnoses. Or Assessment documentation is lacking.
Focus on therapy Plan:
• A therapy plan for the patient that addresses psychotherapy; one well being promotion exercise and one patient schooling technique; plan for therapy and administration, together with various therapies; pharmacologic and nonpharmacologic remedies, various 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 therapy plan for the patient that addresses psychotherapy, well being promotion and patient schooling, therapy and administration, pharmacologic and nonpharmacologic remedies, various therapies, and follow-up parameters. A transparent and concise rationale for the therapy approaches beneficial is provided. 16 (16%) – 17 (17%)
The video clearly outlines an acceptable therapy plan for the patient that addresses psychotherapy, well being promotion and patient schooling, therapy and administration, pharmacologic and nonpharmacologic remedies, various therapies, and follow-up parameters. A transparent rationale for the therapy approaches beneficial is provided. 14 (14%) – 15 (15%)
The response considerably vaguely or inaccurately outlines a therapy plan for the patient and offers a rationale for the therapy approaches beneficial. zero (zero%) – 13 (13%)
The response doesn’t handle the analysis or is lacking parts of the therapy plan.
Replicate on this case. Focus on what you discovered and what you would possibly do in a different way. 5 (5%) – 5 (5%)
Reflections are thorough, considerate, and display important pondering. four (four%) – four (four%)
Reflections display important pondering. three.5 (three.5%) – three.5 (three.5%)
Reflections are considerably basic or don’t display important pondering. zero (zero%) – three (three%)
Reflections are incomplete, inaccurate, or lacking.
Focused SOAP Note documentation 18 (18%) – 20 (20%)
The response clearly, precisely, and totally follows the Focused SOAP Note format to doc the chosen patient case. 16 (16%) – 17 (17%)
The response precisely follows the Focused SOAP Note format to doc the chosen patient case.
