The patient is a 15?year?old Puerto Rican adolescent female living with both her parents and a younger sibling. Her parents presented with signifi

Suicidal Ideation and Depression in Adolescent

The patient is a 15‐year‐old Puerto Rican adolescent female living with both her parents and a younger sibling. Her parents presented with significant marital problems, had been separated several times and were discussing divorce. Her mother reported having a history of psychiatric treatment for depression and anxiety and indicated that the patient's father suffered from bipolar disorder and had been receiving psychiatric treatment. He was hospitalized on multiple occasions during previous years for serious psychiatric symptoms.

The patient is failing several classes in school, and her family was in the process of looking for a new school due to her failing grades and difficulties getting along with her classmates. She presented the following symptoms: frequent sadness and crying, increased appetite and overeating, guilt, low self‐concept, anxiety, irritability, insomnia, hopelessness, and difficulty concentrating. In addition, she presented difficulties in her interpersonal relationships, persistent negative thoughts about her appearance and scholastic abilities, as well as guilt regarding her parents' marital problems. She states that sometimes she feels the world would never know if she disappeared.

The patient's medical history reveals that she suffers from asthma, used eyeglasses, and is overweight. Her mother reported that she had been previously diagnosed with MDD 3 years ago and was treated intermittently for 2 years with supportive psychotherapy and anti‐depressants (fluoxetine and sertraline; no dosage information available). This first episode was triggered by rejection by a boy for whom she had romantic feelings. Her most recent episode appeared to be related to her parents' marital problems and to academic and social difficulties at school.

Chafey, M. I. J., Bernal, G., & Rossello, J. (2009).  Clinical Case Study: CBT for Depression in A Puerto Rican Adolescent. Challenges and Variability in Treatment Response. Depression and Anxiety, 26, 98-103 . https://doi.org/10.1002/da.20457

This assignment requires a comprehensive SOAP format. So, all information from the subjective, objective, assessment, and plan must be included. In the plan portion make sure to include the following:

Pharmacological treatment needs to be specific; give a particular medication with dosing and frequency

Non-pharmacological treatment-give a specific example like CBT, MBSR, Patient Education Referral to other providers, Follow-up.

Use the Case Study template to show your assessment collection data as well as the thought processes for diagnosis and treatment. Support your diagnosis and treatment plan with a minimum of two references in APA form.

Initial Psychiatric SOAP Note Template

Criteria	Clinical Notes
Informed Consent	Informed consent given
Subjective	Verify Patient Name: DOB: Minor: Accompanied by: Demographic: Gender Identifier Note: CC: HPI: SI/ HI/ AV: Allergies: Past Medical Hx: Medical history: Surgical history If Minor obtain Developmental Hx: Nutritional status Past Psychiatric Hx: Previous psychiatric diagnoses: . Previous medication trials: Safety concerns: History of Violence to Self: History of Violence t o Others: Auditory Hallucinations: Visual Hallucinations: Mental health treatment history discussed: History of outpatient treatment: Previous psychiatric hospitalizations: Prior substance abuse treatment: Trauma history: Substance Use: Current Medications: Past Psych Med Trials: Family Medical Hx: Family Psychiatric Hx: Substance use Suicides Psychiatric diagnoses/hospitalization Developmental diagnoses Social History: Occupational History: currently Military service History: Education history: Developmental History: (Childhood History) Legal History: Spiritual/Cultural Considerations: ROS: Constitutional: Eyes: ENT: Cardiac: Respiratory: GI: GU Musculoskeletal: Skin Neurologic: Endocrine: Hematologic: Allergy: Reproductive:
Verify Patient: Name, Assigned  identification number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo. 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. Social History, Family History. Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…”
Objective	Vital Signs: Temp: BP: HR: R: O2: Pain: Ht: Wt: BMI: BMI Range: LABS: Lab findings Tox screen: Alcohol: HCG: Physical Exam: MSE: Diagnostic testing:
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.
Assessment	DSM5 Diagnosis: with ICD-10 codes (Actual and Differentials)
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
Plan	Billing Codes for visit: ____________________________________________
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.

SOAP Note Components

S: Subjective

1. Chief Complaint

1. HPI

1. Past Psychiatric History

2. Age of manifestations of symptoms

2. Previous Diagnoses and when they were diagnosed

2. Psychotropic History

2. All psychotropic medications

2. Why stopped

2. How long they were on

2. Adherence

2. Suicide Attempt/Homicidal Ideation History

2. Legal History

4. Taken to detention center?

4. Involved in youth court?

4. Suspended or expelled from school?

2. Trauma History

5. Abuse?

5. Has it been reported & to whom?

1. Substance Use History

3. Address

0. Tobacco

0. Alcohol

0. Abuse of Prescription Drugs or Illicit Substances

3. Length of time used substances

3. Last Use

3. Sobriety

3. Detox/Rehab history

3. Withdrawal Symptom History

1. Social History

4. Where born and raised

4. Parental history

1. Married or divorced during childhood

1. Relationship with parents during childhood and now

4. Siblings

2. How many and where they are in the order

4. Any developmental issues

4. Highest level of education

4. Current employment status

5. If on disability – list why they are on disability

4. Relationship status

6. Married

6. Divorced

6. Single

6. Widowed

4. Children

7. Number

7. Ages

7. Relationship

4. Living arrangements

8. Who they live with

8. Do they feel safe

4. School

4. Grade in school

4. Favorite thing to do in free time

1. Past medical history/surgical history

1. Family medical/psychiatric history

O: Objective

1. Review of Systems/Physical Assessment

1. Mental Status Exam

8. Appearance

8. Speech

8. Mood

8. Affect

8. Thought Process

8. Thought Content

8. Cognition

8. Insight

8. Judgment

1. Psychiatric Screening Tools if any are utilized during the appointment and their results (Example PHQ-9 is 21 and very difficult

1. Diagnostic Tests Reviewed

10. Make sure to include any pertinent results

0. Laboratory results reviewed with patient, discussed abnormal Vitamin D level and treatment options

10. If no issues with labs:

1. Laboratory results reviewed with patient, no abnormal results noted

A: Assessment

1. Differential Diagnoses

11. With rationale

11. May write this as MDD vs Bipolar d/o, for example

1. Definitive Diagnoses

12. With rationale

12. Must Include ICD Codes

12. The number of diagnoses can affect your reimbursement as a provider

P: Plan

1. Treatment Plan/Plan of Care

13. One of the most important parts of the note

13. Include the following

1. Medication management

0. Medication, Dose, Route, Time

0. State Reason for the medication

0. State reason for any changes & your thinking for future considerations

2. Discontinued Abilify related to side effects of weight gain

2. Increase Lexapro to 10mg daily for depression and anxiety, if patient continues to have depressive symptoms may increase to 15mg at next appointment

2. Decreased Seroquel to 100mg daily at bedtime for sleep as the patient c/o increased daytime fatigue

0. Include a statement such as

3. Risks, benefits and side effects were discussed in-depth with the patient.

3. Patient’s medications were eprescribed and sent to the patient’s designated pharmacy

1. Include any diagnostics that were ordered at this appointment

1. Complementary and Alternative Approaches

1. Include referral for therapy

3. Include type of therapy and why you are recommending

3. Example

1. Patient was referred for EMDR due to history of trauma

1. Patient was referend for DBT due to history of borderline personality disorder

1. Include any type of referrals for anyone else and why

4. It is recommended that the patient follow-up with PCP for any medical issues.

4. Will refer patient out for neuropsychological examination for cognitive decline

1. Include Follow-Up appointment

1. Include CPT Codes for visit

JB 7/5/2024

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