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.
- 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.
- 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.
- All SOAP notes must be signed, and each page must be initialed by your Preceptor.
- 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.
Record yourself presenting the complex case for your clinical patient.
Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video.
In your presentation:
- Dress professionally 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: In your video, describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session?
- In your written plan include all the above as well as include one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
- 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.
Expert Answer and Explanation
SOAP Note for Major Depressive Disorder
CC (chief complaint): “I have had depression for many years.”
HPI: MM is a 24-years-old female of white origin who came to group therapy complaining of depression since the age of 13. She noted that she started experiencing relational and emotional difficulties with her family, especially her sisters. She also noted that she sometimes has a depressed mood and feels low. She reported a loss of interest in her job which she loved before. Associated symptoms include fatigue, weakness, and unintended weight loss. Her depression severity is 7/10.
Past Psychiatric History:
- General Statement: Her first treatment for depression was at the age of 13.
- Caregivers: No caregivers.
- Hospitalizations: No hospitalization. She also denies suicidal and homicidal thoughts.
- Medication trials: No medical trials.
- Psychotherapy or Previous Psychiatric Diagnosis: She was diagnosed with MDD at the age of 13.
Substance Current Use and History: Denies tobacco, cocaine, heroin, alcohol, or any drug use.
Family Psychiatric/Substance Use History: No family history of substance uses or mental health problems.
Psychosocial History: She was born and raised in New York City by her parents until the age of 12. Her parents divorced when she was 13 and moved to Aurora, Colorado with her mother. She has three siblings, two sisters and a brother. She is the second born in the family. She is not married and single. She has no children. She lives with her alone in school. She is pursuing her degree in economics. She likes football but has not gone to training for the last two months. She does not work. She reports no history of violence, trauma, or legal issues.
Medical History: No underlying mental problem.
- Current Medications: No medications.
- Allergies: No allergies.
- Reproductive Hx: She is sexually active. No reproductive abnormalities.
- GENERAL: Reports fatigue, weakness, and unintended weight loss.
- HEENT: Non-contributory.
- SKIN: She denies dryness, itching, or rashes.
- CARDIOVASCULAR: No chest discomfort, pain, or swelling
- RESPIRATORY: No shortness of breath.
- GASTROINTESTINAL: No nausea, abdominal pain, or diarrhea.
- GENITOURINARY: No UTI or burning or urination.
- NEUROLOGICAL: No neurological disorders.
- MUSCULOSKELETAL: No joint or muscle abnormalities.
- HEMATOLOGIC: No bruising.
- LYMPHATICS: No history of splenectomy.
- ENDOCRINOLOGIC: No endocrinologic abnormalities.
Vital Signs: T 36.5, HR 78, BP 111/90, Ht. 5’5 Wt. 56kgs, RR 18.
- HEENT: Head: Non-contributory.
- Skin: Warm, no rash, and dry.
- CV: No murmurs, chest clear, no chest swelling. Regular heart rate and rhythm.
- Respiratory: No distress while breathing. No wheezes.
The Hopkins Symptoms Checklist with 25 Items (HSCL-25): HSCL-25 is one of the tools used to screen for depression. Skogen et al. (2017) note that the tool can help a mental health professional screen for anxiety or depression. The HSCL-25 results show that the patient has depression.
Mental Status Examination: She is dressed inappropriately. She has good eye contact, is on the verge of tears, appears calm, relates well. Speech volume and rate are standard. She was shaking when talking about her emotional feelings. She denies any homicidal or suicidal thoughts. She is A&O x4. She reports poor concentration. Her memory is intact. Her thoughts are intact. She denies hallucinations, delusions, or paranoid thoughts. She reports low mood and affect.
- Recurrent MDD DSM-5 (296.99 (F34.8)
- MDD DSM-5 296.33 (F33.2)
- Bipolar II Disorder DSM-5 (296.89 (F31. 81)
The primary diagnosis is severe recurrent MDD. Recurrent MDD is associated with repeated depression episodes without reports of independent episodes of mania, increased energy, or mood elevation (Yan et al., 2019). Individuals with recurrent MDD have had at least a single depressive symptom for a minimum of two weeks. The patient is said to have recurrent MDD because she has experienced repeated episodes of MDD. The second disorder is MDD. The patient reports a depressed mood, lack of interest in things she loved before, fatigue, weakness, and unintended weight loss which are all symptoms of MDD (Bot et al., 2019). However, the MDD is not initial because the patient has experienced the symptoms since age 13. The last diagnosis is bipolar II disorder. The disorder causes depressive episodes and that is why it is part of the diagnosis (McKnight et al., 2017). However, it is a secondary disorder because it causes hypomania and the patient does not have hypomania (APA, 2013).
I agree with the preceptor’s diagnosis. She also noted that the patient has recurrent MDD which is correct. I have learned from this case that recurrent MDD is hard to diagnose. If I was given the chance again, I would have included MRI as part of the diagnostic studies to improve my diagnosis. In terms of ethical considerations, I would consider our professional boundaries. I would ensure that we maintain a professional relationship. Another ethical issue is veracity (Hsin & Torous, 2016). I will ensure that I use facts to made decision.
Case Formulation and Treatment Plan:
The patient has recurrent MDD. She should start Zoloft 25mg orally daily in addition to the CBT group therapy she is currently undergoing. Duffy et al. (2019) reported that Zoloft is an effective treatment for depression. Hence, combining Zoloft and CBT group therapy can improve her depressive symptoms.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Author.
Bot, M., Brouwer, I. A., Roca, M., Kohls, E., Penninx, B., Watkins, E., van Grootheest, G., Cabout, M., Hegerl, U., Gili, M., Owens, M., Visser, M., & MooDFOOD Prevention Trial Investigators (2019). Effect of multinutrient supplementation and food-related behavioral activation therapy on prevention of major depressive disorder among overweight or obese adults with subsyndromal depressive symptoms: The MooDFOOD randomized clinical trial. JAMA, 321(9), 858–868. https://doi.org/10.1001/jama.2019.0556
Duffy, L., Lewis, G., Ades, A., Araya, R., Bone, J., Brabyn, S., … & Woodhouse, R. (2019). Antidepressant treatment with sertraline for adults with depressive symptoms in primary care: the PANDA research programme including RCT. Programme Grants for Applied Research, 7(10), 108. https://doi.org/10.3310/pgfar07100
Hsin, H., & Torous, J. (2016). Ethical issues in the treatment of depression. Focus (American Psychiatric Publishing), 14(2), 214–218. https://doi.org/10.1176/appi.focus.20150046
McKnight, R. F., Bilderbeck, A. C., Miklowitz, D. J., Hinds, C., Goodwin, G. M., & Geddes, J. R. (2017). Longitudinal mood monitoring in bipolar disorder: course of illness as revealed through a short messaging service. Journal of Affective Disorders, 223, 139-145. https://doi.org/10.1016/j.jad.2017.07.029
Skogen, J. C., Øverland, S., Smith, O. R., & Aarø, L. E. (2017). The factor structure of the Hopkins Symptoms Checklist (HSCL-25) in a student population: a cautionary tale. Scandinavian Journal Of Public Health, 45(4), 357-365. https://doi.org/10.1177%2F1403494817700287
Yan, C. G., Chen, X., Li, L., Castellanos, F. X., Bai, T. J., Bo, Q. J., … & Zang, Y. F. (2019). Reduced default mode network functional connectivity in patients with recurrent major depressive disorder. Proceedings of the National Academy of Sciences, 116(18), 9078-9083. https://doi.org/10.1073/pnas.1900390116
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