FOCUSED SOAP NOTE FOR ANXIETY, PTSD, AND OCD
FOCUSED SOAP NOTE FOR ANXIETY, PTSD, AND OCD
In assessing patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders, you will continue the practice of looking to understand chief symptomology in order to develop a diagnosis. With a differential diagnosis in mind, you can then move to a treatment and follow-up plan that may involve both psychopharmacologic and psychotherapeutic approaches.
In this Assignment, you use a case study to develop a focused SOAP note based on evidence-based approaches.
RESOURCES Required Readings
• Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.
o Chapter 2, “Neurodevelopmental Disorders and Other Childhood Disorders”
Section 2.8, “Trauma- and Stressor-Related Disorders in Children” (pp. 167-173)
Section 2.13, “Anxiety Disorders of Infancy, Childhood, and Adolescence: Separation Anxiety Disorder, Generalized Anxiety Disorder, and Social Anxiety Disorder (Social Phobia)” (pp. 194-200”)
Section 2.14, “Selective Mutism” (pp. 201-202)
Section 2.15, “Obsessive-Compulsive Disorder in Childhood and Adolescence” (pp. 203-206)
o Chapter 8, “Anxiety Disorders”
o Chapter 9, “Obsessive-Compulsive and Related Disorders”
o Chapter 10, “Trauma- and Stressor-Related Disorders
• Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (Eds.). (2015). Rutter’s child and adolescent psychiatry (6th ed.). Wiley Blackwell.
o Chapter 26, “Psychosocial Adversity”
o Chapter 27, “Resilience: Concepts, Findings, and Clinical Implications”
o Chapter 29, “Child Maltreatment”
o Chapter 30, Child Sexual Abuse”
o Chapter 58, “Disorders of Attachment and Social engagement Related to Deprivation”
o Chapter 59, “Post Traumatic Stress Disorder”
• Zakhari, R. (2021). The psychiatric-mental health nurse practitioner certification review manual. Springer Publishing Company.
o Chapter 6, “Physical Assessment, Diagnostic Tests, and Differential Diagnosis”
o Chapter 12, “Anxiety Disorders”
• Document: Career Planner GuideDownload Career Planner Guide
• Document: Focused SOAP Note TemplateDownload Focused SOAP Note Template
• Document: Focused SOAP Note Exemplar
Required Media
• Centers for Disease Control and Prevention. (2020, April 3). Adverse childhood experiences (ACEs)Links to an external site. [Video].
https://www.cdc.gov/violenceprevention/aces/index.html
• Dartmouth Films. (2018, September 25). Resilience Links to an external site.[Video]. YouTube.
• NCTSN. (2007). The promise of trauma-focused therapy for childhood sexual abuseLinks to an external site. [Video].
https://www.nctsn.org/resources/promise-trauma-focused-therapy-childhood-sexual-abuse-video
• Walden University. (2021). Case study: Dev Cordoba. Walden University Canvas. https://waldenu.instructure.com
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
TO PREPARE
• Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing anxiety, obsessive compulsive, and trauma-related disorders.
• Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
• Review the video, Case Study: Dev Cordoba. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
• Consider what history would be necessary to collect from this patient.
• Consider what interview questions you would need to ask this patient.
THE ASSIGNMENT
Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:
• 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 the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
• Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.
• Reflection notes: What would you do differently with this patient if you could conduct the session again? Discuss what your next intervention would be if you could follow up with this patient. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion, and disease prevention, taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
• Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).
BY DAY 7 OF WEEK 3
Submit your Focused SOAP Note.
SUBMISSION INFORMATION
Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.
1. To submit your completed assignment, save your Assignment as WK3Assgn_LastName_Firstinitial
2. Then, click on Start Assignment near the top of the page.
3. Next, click on Upload File and select Submit Assignment for review.
Rubric
NRNP_6675_Week3_Assignment_Rubric
NRNP_6675_Week3_Assignment_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeCreate documentation in the Focused SOAP Note Template about your assigned patient.In the Subjective section, provide: • Chief complaint• History of present illness (HPI)• Past psychiatric history• Medication trials and current medications• Psychotherapy or previous psychiatric diagnosis• Pertinent substance use, family psychiatric/substance use, social, and medical history• Allergies• ROS 15 to >13.0 pts
Excellent 90%–100%
The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. 13 to >11.0 pts
Good 80%–89%
The response accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. 11 to >10.0 pts
Fair 70%–79%
The response describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis but is somewhat vague or contains minor innacuracies. 10 to >0 pts
Poor 0%–69%
The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Or the subjective documentation is missing.
15 pts
This criterion is linked to a Learning OutcomeIn the Objective section, provide:• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses 15 to >13.0 pts
Excellent 90%–100%
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented. 13 to >11.0 pts
Good 80%–89%
The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented. 11 to >10.0 pts
Fair 70%–79%
Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies. 10 to >0 pts
Poor 0%–69%
The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed. Or the objective documentation is missing.
15 pts
This criterion is linked to a Learning OutcomeIn the Assessment section, provide:• Results of the mental status examination, presented in paragraph form• At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case. 20 to >17.0 pts
Excellent 90%–100%
The response thoroughly and accurately documents the results of the mental status exam…. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected. 17 to >15.0 pts
Good 80%–89%
The response accurately documents the results of the mental status exam…. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the disorders selected. 15 to >13.0 pts
Fair 70%–79%
The response documents the results of the mental status exam with some vagueness or innacuracy…. Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vagueness or innacuracy. 13 to >0 pts
Poor 0%–69%
The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or the assessment documentation is missing.
20 pts
This criterion is linked to a Learning OutcomeIn the Plan section, provide:• Your plan for psychotherapy• Your plan for treatment and management, including alternative therapies. Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. • Incorporate one health promotion activity and one patient education strategy. 25 to >22.0 pts
Excellent 90%–100%
The response provides an evidence-based, detailed, and appropriate plan for psychotherapy for the patient…. The response provides an evidence-based, detailed, and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A strong rationale for the plan is provided that demonstrates critical thinking and content understanding…. The response includes at least one evidence-based health promotion activity and one evidence-based patient education strategy. 22 to >19.0 pts
Good 80%–89%
The response provides an evidence-based and appropriate plan for psychotherapy for the patient…. The response provides an evidence-based and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. An adequate rationale for the plan is provided…. The response includes at least one health promotion activity and one patient education strategy. 19 to >17.0 pts
Fair 70%–79%
The response provides a somewhat vague or inaccurate plan for psychotherapy for the patient…. The response provides a somewhat vague or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is weak or general…. The response includes one health promotion activity and one patient education strategy, but it may contain some vagueness or innacuracy. 17 to >0 pts
Poor 0%–69%
The response provides an incomplete or inaccurate plan for psychotherapy for the patient…. The response provides an incomplete or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is inaccurate or missing…. The health promotion and patient education strategies are incomplete or missing.
25 pts
This criterion is linked to a Learning Outcome• Discussion include what may be done differently with this patient if student conducted the session again. Discussed the next intervention if you could follow up with this patient. The discussion was related to legal/ethical considerations (demonstrated critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention that take into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.). 5 to >4.0 pts
Excellent 90%–100%
Reflections are thorough, thoughtful, and demonstrate critical thinking. Reflections contain a discussion of all elements described within assignment directions. 4 to >3.5 pts
Good 80%–89%
Reflections demonstrate critical thinking. Reflections contain 2 out of 3 (legal/ethical considerations, social determinate of health, health promotion) with consideration of patient factors and risk factors. 3.5 to >3.0 pts
Fair 70%–79%
Reflections are somewhat general or do not demonstrate critical thinking. Reflections contain 2 out of 3 (legal/ethical considerations, social determinate of health, health promotion) without consideration of patient factors and risk factors. 3 to >0 pts
Poor 0%–69%
Reflections are incomplete, inaccurate, or missing.
5 pts
This criterion is linked to a Learning OutcomeProvide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old). 10 to >8.0 pts
Excellent 90%–100%
The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making. 8 to >7.0 pts
Good 80%–89%
The response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study. 7 to >6.0 pts
Fair 70%–79%
Three evidence-based resources are provided to support the assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification. 6 to >0 pts
Poor 0%–69%
Two or fewer resources are provided to support the assessment and diagnosis decisions. The resources may not be current or evidence based.
10 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for parenthetical/in-text citations and reference list. 5 to >4.0 pts
Excellent 90%–100%
Uses correct APA format with no errors 4 to >3.5 pts
Good 80%–89%
Contains 1-2 APA format for parenthetical/in-text citations and reference list errors 3.5 to >3.0 pts
Fair 70%–79%
Contains 3-4 APA format for parenthetical/in-text citations and reference list errors 3 to >0 pts
Poor 0%–69%
Contains five or more APA format for parenthetical/in-text citations and reference list errors
5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and punctuation 5 to >4.0 pts
Excellent 90%–100%
Uses correct grammar, spelling, and punctuation with no errors 4 to >3.5 pts
Good 80%–89%
Contains 1-2 grammar, spelling, and punctuation format errors 3.5 to >3.0 pts
Fair 70%–79%
Contains 3-4 grammar, spelling, and punctuation format errors 3 to >0 pts
Poor 0%–69%
Contains five or more grammar, spelling, and punctuation format errors that interfere with the reader’s understanding
5 pts
Total Points: 100
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