Week 9:Focused SOAP Note and Patient Case Presentation
Introduction
At your practicum web site, you might have been strengthening your communication, Assessment, diagnostic reasoning, and therapy abilities. This week, you spotlight these abilities as you full a targeted SOAP word and current a affected person case in a video, simply as you probably did in Week three and Week 7. You additionally proceed to trace your medical hours and sufferers in Meditrek.
College students will:
• Describe medical hours and affected person encounters
• Assess sufferers throughout the lifespan in psychological well being settings
• Formulate differential diagnoses for sufferers throughout the lifespan in psychological well being settings
• Develop plans of take care of sufferers throughout the lifespan in psychological well being settings
• Advocate well being promotion and affected person schooling methods throughout the lifespan
• Develop a case examine presentation primarily based on a medical affected person
Task 2: Focused SOAP Note and Patient Case Presentation
For this Task, you’ll doc details about a affected person that you just examined over the past three weeks, utilizing the Focused SOAP Note Template offered. You’ll then use this word to develop and document a case presentation for this affected person. Make sure you incorporate any suggestions you acquired in your Week three and Week 7 case displays into this last presentation for the course. Task 2: Patient Case Presentation and Focused SOAP Note
For this Task, you’ll use the Focused SOAP Note Template to doc details about a affected person you examined within the final three weeks. This word will then be used to create and document a case presentation for this affected person. Embrace any suggestions you acquired in your Week three and Week 7 case displays on this last course presentation.
To Put together
• Evaluate the Kaltura Media Uploader useful resource within the left-hand navigation of the classroom for Help creating your self-recorded Kaltura video.
• Choose a baby or adolescent affected person that you just examined over the past three weeks who introduced with a dysfunction for which you haven’t already created a Focused SOAP Note in Weeks three or 7. (For example, when you chosen a affected person with anorexia nervosa in Week 7, you need to select a affected person with one other sort of dysfunction for this week.)
• Create a Focused SOAP Note on this affected person utilizing the template offered within the Studying Sources. There may be additionally a accomplished Focused SOAP Note Exemplar offered to function a information to project expectations.
Please Note:
o All SOAP notes should be signed, and every web page should be initialed by your Preceptor. Note: Digital signatures usually are not accepted.
o If you submit your word, you need to embody the entire targeted SOAP word as a Phrase doc and PDF/pictures of every web page that’s initialed and signed by your Preceptor.
o You need to submit your SOAP word utilizing SafeAssign. Note: If each information usually are not acquired by the due date, college will deduct factors per the Walden Grading Coverage.
• Then, primarily based in your SOAP word of this affected person, develop a video case examine presentation. Take time to observe your presentation earlier than you document.
• Embrace not less than 5 scholarly sources to Help your Assessment, analysis, and therapy planning.
• Guarantee that you’ve the suitable lighting and tools to document the presentation.
The Task
File your self presenting the advanced case in your medical affected person.
Don’t sit and learn your written analysis! The video portion of the project is a simulation to reveal your skill to succinctly and successfully current a posh case to a colleague for a case session. The written portion of this project is a simulation so that you can reveal to the school your skill to doc the advanced case as you’ll in an digital medical document. The written portion of the project can be used as a information for college to evaluate your video to find out if you’re omitting pertinent info or together with non-essential info throughout your case staffing session video.
In your presentation:
• Gown professionally and current your self in an expert method.
• Show your photograph ID at the beginning of the video once you introduce your self.
• Be sure that you don’t embody any info that violates the ideas of HIPAA (i.e., don’t use the affected person’s title or another figuring out info).
• Current the complete advanced case examine. Embrace chief criticism; historical past of current sickness; any pertinent previous psychiatric, substance use, medical, social, household historical past; most up-to-date psychological standing examination; present psychiatric analysis together with differentials that have been dominated out; and plan for therapy and administration.
• Report regular diagnostic outcomes because the title of the check and “regular” (reasonably than particular worth). Irregular outcomes must be reported as a particular worth.
• Be succinct in your presentation, and don’t exceed eight minutes. Particularly handle the next for the affected person, utilizing your SOAP word as a information:
o Subjective: What particulars did the affected person present concerning their chief criticism and symptomology to derive your differential analysis? What’s the length and severity of their signs? How are their signs impacting their functioning in life?
o Goal: What observations did you make throughout the psychiatric Assessment?
o Assessment: Talk about their psychological standing examination outcomes. What have been your differential diagnoses? Present a minimal of three doable diagnoses and why you selected them. Listing them from highest precedence to lowest precedence. What was your major analysis, and why? Describe how your major analysis aligns with DSM-5 diagnostic standards and supported by the affected person’s signs.
o Plan: In your video, describe your therapy plan utilizing medical observe pointers supported by evidence-based observe. Embrace a dialogue in your chosen FDA-approved psychopharmacologic brokers and embody different remedies out there and supported by legitimate analysis. All therapy selections should have a dialogue of your rationale for the selection supported by legitimate analysis. What have been your follow-up plan and parameters? What referrals would you make or advocate on account of this therapy session?
o In your written plan embody all of the above in addition to embody one social determinant of well being based on the HealthyPeople 2030 (you will have to analysis) as utilized to this case within the realm of psychiatry and psychological well being. As a future superior supplier, what are one well being promotion exercise and one affected person schooling consideration for this affected person for bettering well being disparities and inequities within the realm of psychiatry and psychological well being? Exhibit your crucial pondering.
o Reflection notes: What would you do otherwise with this affected person when you might conduct the session over? If you’ll be able to comply with up along with your affected person, clarify whether or not these interventions have been profitable and why or why not. If you weren’t capable of conduct a comply with up, talk about what your subsequent intervention could be.
Talk about Subjective knowledge:
• Chief criticism
• Historical past of current sickness (HPI)
• Medicines
• Psychotherapy or earlier
psychiatric analysis
• Pertinent histories and/or ROS
The video precisely and concisely presents the affected person’s subjective criticism, historical past of current sickness, medicines, psychotherapy or earlier psychiatric analysis, and pertinent histories and/or evaluate of methods that may inform a differential analysis
Talk about Goal knowledge:
• Bodily examination documentation of methods 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
The video precisely and concisely paperwork the affected person’s bodily examination for pertinent methods. Pertinent diagnostic checks and their outcomes are documented, as relevant.
Talk about outcomes of Assessment:
• Outcomes of the psychological standing examination
• Present a minimal of three doable diagnoses so as 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 affected person’s signs.
The video precisely paperwork the outcomes of the psychological standing examination.
Video presents not less than three differentials so as of precedence for a differential analysis of the affected person, and a rationale for his or her choice. Response justifies the first analysis and the way it aligns with DSM-5 standards.
Talk about therapy Plan:
• A therapy plan for the affected person that addresses chosen FDA-approved psychopharmacologic brokers and consists of different remedies out there and supported by legitimate analysis. The therapy plan consists of rationales, a plan for follow-up parameters, and referrals. The dialogue consists of one social determinant of well being based on the HealthyPeople 2030, one well being promotion exercise and one affected person schooling consideration for this affected person for bettering well being disparities and inequities within the realm of psychiatry and psychological well being.
The video clearly and concisely outlines an evidence-based therapy plan for the affected person that addresses FDA-approved psychopharmacologic brokers and consists of different remedies and rationale supported by legitimate analysis.
Dialogue features a clear and concise follow-up plan and parameters.
The dialogue features a clear and concise referral plan.
The paper dialogue incorporates all three parts from the project instructions together with a dialogue demonstrating crucial pondering of the case associated to the Wholesome Individuals 2030 social well being determinates. Clearly and concisely relates dialogue to the psychiatric and psychological well being subject.
Replicate on this case. Talk about what you realized and what you would possibly do otherwise.
Reflections are thorough, considerate, and reveal crucial pondering.
The response clearly, precisely, and completely follows the Focused SOAP Note format to doc the chosen affected person case.
