Each student will create a focused SOAP note or PowerPoint presentation.
Each student will create a focused SOAP note or PowerPoint presentation. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive psychiatric SOAP note is to be written using the attached template below. Only the information asked in the video will be used for grading.
S =
Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS). Click hereLinks to an external site. for more information
O =
Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; and Mental Status Exam
A =
Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes
P =
Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up
for this soap note we will use and encounter date september 7, 2023.pt name is genesis. female 11 years old Hispanic.
mom brings her to the office. she says her daughter, lately in school is getting calls from the teacher saying pt is not concentrating in school, talking a lot, and not paying attention. difficulties listening even at home. when asked about sleep and eating habits. lately, she woke up every four hours. no unknown allergies. pt overall WNL. She was hospitalized for COVID 5 months ago. she stayed in the hospital for a week. pt lives at home with her mom dad and older brother. her relationship with her brother is good.pt has no pas medical history or pys history,. same for the mom and dad. WDL. NO PAST MEDICAL HISTORY. diagnosis ADHD.
secondary diagnosis is an anxiety disorder. start pt on medication. pharmacological medication is 10mg aderal. add education about medication and make sure to add APA references at the end. also, add cbt COGNITIVE BEHAVIORAL THERAPY for non pharmacological treatment
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