Create a focused SOAP note for a an adult with a significant psychiatric problem
Create a focused SOAP note for a an adult with a significant psychiatric problem. Discuss subjective data:• Chief complaint• History of present illness (HPI)• Medications• Psychotherapy or previous psychiatric diagnosis• Pertinent histories and/or ROS. Discuss objective data:• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses. Discuss results of assessment: • Results of the mental status examination• Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.
Discuss treatment plan: • A treatment plan for the patient that addresses psychotherapy; one health promotion activity and one patient education strategy; plan for treatment and management, including alternative therapies; pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters; and a rationale for the approaches selected. Discusses an identified social determinate of health impacting this patient’s mental health status and provide your recommendation for a referral to assist this patient in meeting this identified need
Reflect on this case. Discuss what you learned and what you might do differently. Pose 3 questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing
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