Exercise Content: Child Psychiatric SOAP NOTE TEMPLATE ( FOLLOW TEMPLATE FOR CASE SCENARIO)

Exercise Content: Child Psychiatric SOAP NOTE TEMPLATE ( FOLLOW TEMPLATE FOR CASE SCENARIO)

 

ASSIGNMENT;

A case scenario pertains to Anxiety, Obsessive-compulsive disorder, or specific phobias.

Please submit a term paper with a cover page and content page.

Your paper should cover the points presented below. This assignment is SafeAssign for originality.

 

Psychiatric SOAP Note Template

  Criteria

 Clinical Notes

 Informed Consent 

 Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. 

Please select one choice from below statement: 

 

___ Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion).

 

___ Patient doesn’t have the ability/capacity to respond and appears to not understand the risk, benefits, and (Will review additional consent during treatment plan discussion)

 

  Subjective Data

 

   Verify Patient: Name, Assigned identification number (e.g., medical record number), Date of birth, Phone number, age, marital status, Gender, ethnicity. 

Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview. 

 

HPI:

Past Medical and Psychiatric History, Current Medications, Previous Psych Med trials, Allergies

 Verify Patient Name and DOB:

 

Minor: Accompanied by:________________

 

 Chief Complaint (CC): ___________“in patient’s own words” reason for visit-restate in case formulation

 

 History of Present Illness (HPI):

 

PQRST or OLDCARTS related to the presenting problem.

 

Focus includes: precipitating factors

 

                        current/recent stressors 

 

                        Reason for seeking help now.

 

Pertinent history in the record and from the patient: X

 

During assessment, The patient describes their mood as X and indicates it has gotten worse in TIME.

 

Patient’s self-esteem appears fair; no reported feelings of excessive guilt, no reported anhedonia, no sleep disturbance, does not report change in appetite, does not report libido disturbances, does not report change in energy, no reported changes in concentration or memory.

 

The patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. The patient does not report excessive fears, worries, or panic attacks. The patient does not report hallucinations, delusions, obsessions, or compulsions. The patient’s activity level, attention, and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a characterological nature.

 

SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, and denies inappropriate/illegal behaviors.

 

Past Medical Hx: 

Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury.Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C.Surgical history no surgical history reported.

 

Past Psychiatric Hx: 

Previous psychiatric diagnoses: none reported.

 

Describes course of illness if any. _____________________________

 

 Allergies: NKDFA.(medication & food)

 

   Social History, Family History. Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…

 Safety concerns: 

History of Violence to Self: none reported 

 

History of Violence to Others: none reported    

 

Auditory Hallucinations: none reported    

 

Visual Hallucinations: none reported  

 

 Trauma history: 

Client does not report history of trauma including abuse, domestic violence, witnessing disturbing events.

 

 

Substance Use: 

Client denies use or dependence on nicotine/tobacco products. Client does not report abuse of or dependence on ETOH, and other illicit drugs.

 

 

Past Psych Med Trials: 

 

Current Psych Medications:

 

 Family Psychiatric Hx:      

 

Substance use: not reported        

 

Suicides:  not reported     

 

Psychiatric diagnoses/hospitalization: not reported       

 

Developmental diagnoses: not reported

 

Others: not reported

 

 Social History: 

Occupational History: currently unemployed. Denies previous occupational hx Military service History: Denies previous military hx.

Education history: completed HS and vocational certificate 

Developmental History: (Childhood History): no significant details reported

Legal History: no reported/known legal issues, no reported/known conservator or guardian. 

Spiritual/Cultural Considerations: none reported.

ROS:

Constitutional: No report of fever or weight loss.

Eyes: No report of acute vision changes or eye pain. 

ENT: No report of hearing changes or difficulty swallowing. 

Cardiac: No report of chest pain, edema or orthopnea. 

Respiratory: Denies dyspnea, cough or wheeze. 

GI: No report of abdominal pain. 

GU: No report of dysuria or hematuria. 

Musculoskeletal: No report of joint pain or swelling. 

Skin: No report of rash, lesion, abrasions. 

Neurologic: No report of seizures, blackout, numbness or focal weakness. Endocrine: No report of polyuria or polydipsia. 

Hematologic: No report of blood clots or easy bleeding. 

Allergy: No report of hives or allergic reaction. 

Reproductive: No report of significant issues. 

 

(females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…)

 

Pain:________________                      

 

   Objective Data 

 This is where the “facts” are located. Vitals, **Physical Exam (if performed, will not be performed every visit in every setting) Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results.

 Vital Signs: 

 

Ht:_________________            

 

Wt:_________________            

 

BMI: _______________           

 

BMI Range:__________

 

 LABS:

 

Lab findings: WNL

 

Tox screen: Negative

 

Alcohol: Negative

 

HCG: N/A

 

 Risk assessment: suicide/violence

 

Mental Status Examination (MSE)

 

a) Appearance: 

 

b) Behavior and psychomotor activity

 

c) Consciousness

 

d) Orientation

 

e) Memory

 

f) Concentration and attention

 

g) Intellectual functioning

 

h) Speech and language

 

i) Perceptions

 

j) Thought processes

 

k) Thought content

 

l) Suicidality or homicidal

 

m) Mood

 

n) Affect

 

o) Judgment

 

p) Insight

 

q) Reliability

 

 Psychiatric Review of System (Psych ROS)

 

a) Anxiety

 

b) Mania

 

c) Depression

 

d) Schizophrenia

 

e) Panic attacks

 

f) PTSD

 

g) OCD

 

h) ADHD

 

i) Eating disorders

 

j) Personality Disorders

 

 

 

Diagnostic testing: 

 

PHQ-9, psychiatric assessment

 

 

  Assessment

 

  

 Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment.

 

Informed Consent Ability

 

 Impression formulation: 

 

 

 

DSM5 Diagnosis: with ICD-10 codes:

 

 

 

Differential Diagnosis: 

 

Dx: –  

 

 

 

Dx: – 

 

  

 

Dx: –

 

 

 

Patient has the ability/capacity appears to respond to psychiatric medications/psychotherapy and appears to have the need for medications/psychotherapy and is willing to maintain adherent. Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment.

 

  Clinical Plan

 

  

 

 Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options and complimentary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment and include patient education.

 

 Inpatient:

 

Psychiatric. Admits to X as per HPI.

 

Estimated stay 3-5 days

 

Patient is found to be very anxious and aggressive behavior.

 

 Patient likely poses a high-risk harm to self and harm risk to others at this time. Patient has abnormal perceptions and it appear to be responding to internal stimuli. 

 

 

Pharmacologic interventions / treatment: 

 

Including dosage, route, and frequency and non-pharmacologic:

 

 Education: including health promotion, maintenance, and psychosocial needs:

 

•Psychoeducation

 

•Mindfulness and Relaxation:

 

•Importance of medication

 

•Discussed current tobacco use. NRT  indicated. 

 

•Safety planning

 

•Discuss worsening sx and when to contact office or report to ED

 

 > 50% time spent counseling/coordination of care.

 

Time spent in Psychotherapy:  18 minutes

 

Visit lasted: 55 minutes

 

 Referrals:

 

        Psychotherapy referral for CBT

 

        Endocrinologist for diabetes

 

        Other

 

 

 

 

 

Follow-up:

including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit 2 weeks

 

   References

AT LEAST 4 REFERENCES WITHIN 5 YEARS

 

 

 

 

 

  

 

 

 

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