Create a soap note for a patient with bipolar disorder
Unit 5 Clinical SOAP Note. 800w not anessay. Due late on 6-6-24
Instructions
Each week students will choose one patient encounter to submit a Follow-up SOAP note for review.
This week create a soap note for a patient with bipolar disorder.
The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.
Submit this SOAP Note to this week’s discussion for peer review.
Depression SOAP Note Template
Subjective:
Chief complaint: Patient reports feeling “hopeless” and lacking motivation.
History of present illness: Patient describes a 3-month history of depressive symptoms.
Relevant personal and social history: Recent relationship breakup, social isolation, family history of depression.
Objective:
Appearance: Disheveled, poor eye contact, flat affect.
Behavior: Slow speech, minimal spontaneous movement.
Psychiatric symptoms: Reports persistent sadness, loss of interest in activities, fatigue, and difficulty concentrating.
Assessment:
Diagnosis: Major Depressive Disorder (MDD).
Progress: Patient has been attending bi-weekly therapy sessions for 1 month with minimal improvement in symptoms.
Plan:
Increase therapy sessions to weekly and incorporate cognitive-behavioral techniques.
Schedule a medication evaluation with a psychiatrist.
Encourage patient to engage in social activities and regular physical activity.
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