SOAP-Generalized Anxiety disorder
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Write a SOAP Note on a 27-year-old client with generalized anxiety disorder, currently taking Duloxetine 20 mg twice a day. Report fogginess and headache since he started taking the medication
NKA, Smokes I pack cigarettes a week. smokes marijuana periodically.
Curemtly in Babylon group
RUBIC
Subjective Data
CC is clear, concise and verbatim from pt. HPI is thorough yet concise and provides a chronological account of symptoms and contextual factors that are sufficiently descriptive (oldcarts) to validate Dx per DSM-5 criteria. All pertinent negatives are included. A longitudinal course of illness is clear. Current psychiatric medications and response are included.
Objective Data
MSE contains required elements.
Is in narrative form and effectively and vividly describes the patient’s presentation. Concrete examples of all assessment results are included i.e.. “able to correctly interpret 2/3 simple proverbs” to validate documentation of “abstract thought intact”.
Assessment
Differential diagnosis is pertinent to S&S, formulation contains evidence of critical thought and subject knowledge, and reasonable diagnoses are made per DSM-5. Clearly met criteria for diagnoses tendered are explicit in the HPI description and substantiated with the MSE
Plan
Evidence-based treatment plan is presented with detailed rationales. Level of detail reflects the student’s ability to choose treatments based not only on FDA approval or current evidence but also the nuances and unique characteristics of each. Treatment plan is holistic and comprehensive. There is strong evidence of the student’s synthesis of information and critical thought. Includes neurobiology information on the disorder
Writing, Support, APA
The format is consistent with the example provided in the course. Strong, recent (5-7 years), scholarly, peer- reviewed support of topics. No grammar, spelling, and punctuation errors. Writing mechanics are consistent with formal scholarly work. No errors in APA style based upon the required APA manuals listed on the course syllabi.
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