Case study with SOAP note and Safety plan. Template attached. Read the case study, complete an initial assessment soap note and develop a safety plan for Jill. Add a sho

Assignment Details

Read the case study, complete an initial assessment soap note and develop a safety plan for Jill. Add a short narrative about educating the family and patient about safety of environment and coping strategies to help the patient through any times involving suicidal thoughts or thoughts of self-harm. Consider if she should be admitted for monitoring or scheduled for more frequent follow-ups, what type of psychotherapy modality would be helpful, et cetera.

Jill is a 50-year-old woman who lives with her husband and two children (aged 20 and 18). She has come to see her PMHNP with worries about a number of health problems including extreme tiredness, agitation and pains in her chest. Past history Jill has been a frequent attender at the practice over the years, often with concerns about her or her children’s health. She experienced postpartum depression with her second child. She has a history of GAD and Depression and has been on and off antidepressants for the past 30 years. When she was 23 she took an overdose following the break-up of a relationship. She had some sessions of counseling about 10 years ago that she found helpful. She was referred to a primary care mental health worker in the practice 2 years ago for help with anxiety and low mood. She had some sessions of individual guided self-help, but she found that this made no difference. She was put in touch with a voluntary sector self-help group for people with anxiety around this time – but did not pursue this. She has no other health history or complaints today related to medical health, no military history. She currently takes no medications and has no allergies. She considers herself healthy as she eats a vegan diet and does walk 2 times a week around the local lake.

On examination Jill says she has always been a very ‘nervy’ person who finds dealing with everyday stresses difficult. She worries a lot about herself and her family and easily gets ‘in a state’ and assumes ‘the worst’ – for example, if family members are unwell or if they are late coming home. Sometimes things get so bad that she needs someone around her constantly to reassure her and feels that she can’t be left on her own. The intensity of these problems has varied over the years, but has become worse again during the past 8 months following her husband’s diagnosis of heart problems. She has been drinking wine most evenings to try to calm herself down. More recently things have become so bad that she has sometimes felt that if she were left on her own she might harm herself. Her family has been very supportive and stayed with her during these periods until she calmed down, but is now finding this difficult to manage. Last night she had an extended period of feeling like everyone would be better off without her. She describes a plan “to drink alcohol, take some of her husband’s pain medications, start her car in the garage and pass out.” She states the only thing that ever helps her is to walk and hum to herself and in the winter she sometimes knits.

Vitals: BP: 122/68 HR: 74 R: 18 T: 97 O2: 99% Pain: 2 on 0–10 scale

Wt.: 147

Ht.: 66”

Psychiatry/Psychotherapy SOAP note TEMPLATE

Patient Name: XXX

MRN: XXX

Date of Service: 01-27-2020

Start Time: 10:00

End Time: 10:54

Billing Code(s): 90213, 90836

(Be sure to include strictly psychotherapy codes or both E&M and add on psychotherapy codes if prescribing provider visit)

Accompanied by: Brother

CC: Follow-up appt. for counseling

HPI: One week from inpatient care to current partial inpatient care daily individual psychotherapy session and extended daily group sessions

S- Patient states that he generally has been doing well with depressive and anxiety symptoms improved but he still feels down at times. He states he is sleeping better, achieving 7-8 hours of restful sleep each night. He states he feels the medication is helping somewhat and without any noticeable side-effects.

Crisis Issues: He states he has no suicide plan and has not thought about suicide since the recent attempt. He states has no access to prescription medications, other than the fluoxetine. He believes the classes he participated in while inpatient have helped him with coping mechanisms.

Reviewed Allergies: NKA

Current Medications: Fluoxetine 10mg daily

ROS: no complaints

O-

Vitals: T 98.4, P 82, R 16, BP 122/78

PE: (not always required and performed, especially in psychotherapy only visits)

Heart- RRR, no murmurs, no gallops

Lungs- CTA bilaterally

Skin- no lesions or rashes

Labs: CBC, lytes, and TSH all within normal limits

Results of any Psychiatric Clinical Tests: BAI=34

MSE:

Gary Davis, a 36-year-old white male, was disheveled and unkempt on presentation to the outpatient office. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age. During the interview, he was attentive and calm. He was impatient, but polite in his interactions with this examiner. Mr. Davis reported that today was the best day of his life, because he had decided he was going to be better and start his own company. His affect was labile, but appropriate to the content of his speech (i.e., he became tearful when reporting he had “bogeyed number 15” in gold yesterday). His speech was loud, pressured at times then he would quickly gain composure to a more neutral tone. He exhibited loosening of associations and flight of ideas; he intermittently and unpredictably shifted the topic of conversation from golf, to the mating habits of geese, to the likelihood of extraterrestrial life. Mr. Davis described grandiose delusions regarding his sexual and athletic performance. He reported no auditory hallucinations. He was oriented to time and place. He denied suicidal and homicidal ideation. He refused to participate in intellectual- or memory-related portions of the examination. Reliability, judgment, and insight were impaired.

A – with (ICD-10 code)

Differential Diagnoses:

1. choose 3 differential diagnoses

2.

3.

Definitive Diagnosis:

Major Depressive Disorder, recurrent, without psychotic features F33.4

Generalized Anxiety Disorder F41.1

P- Continue Fluoxetine increasing dose to 20mg.

Continue outpatient counseling: partial inpatient program continued with individual and group sessions

Psychotherapy Modality used: CBT

Interventions/Homework: Two distortion worksheets, keep track of physical symptoms of anxiety or depression and triggers associated

Educations: Discussed smoking cessation

Reviewed medication side effects and adherence importance

Follow-up: in one week or earlier if any depressive symptoms worsen.

Outpatient counseling sessions to continue weekly until further notice.

Referrals: none at this time

Provider Signature: ANNA SMITH, PMHNP-BC

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