Wk7 SOAP NOTE
The shopper is 24 years outdated with a historical past of Bipolar, got here in for her routine go to. She reviews racing ideas, elevated emotionality, and issue staying on process. She reviews sleep is sweet and good appetites. The shopper is at the moment on Lithium 900 mg each day, Abilify 2.5mg, was tapered off Quetiapine. Will begin Clonidine zero.5 mg each day to assist with focus, improve Abilify to 5mg each day and proceed 900mg lithium each day. The shopper states she has scheduled two classes. Refills despatched to the affected person pharmacy. Will see affected person in two three weeks.
Expectation. Use the detailed Rubric on the finish of this doc.
• Current the total advanced case examine. Embrace chief grievance; historical past of current sickness; any pertinent previous psychiatric, substance use, medical, social, household historical past; most up-to-date psychological standing examination; present psychiatric prognosis together with differentials that had been dominated out; and plan for therapy and administration.
• Report regular diagnostic outcomes because the title of the check and “regular” (fairly than particular worth). Irregular outcomes ought to be reported as a particular worth.
Particularly deal with the next for the affected person, utilizing your SOAP be aware as a information:
• Subjective: What particulars did the affected person present concerning their chief grievance and symptomology to derive your differential prognosis? What’s the period and severity of their signs? How are their signs impacting their functioning in life?
• Goal: What observations did you make through the psychiatric evaluation?
• Evaluation: Talk about their psychological standing examination outcomes. What had been your differential diagnoses? Present a minimal of three potential diagnoses and why you selected them. Listing them from highest precedence to lowest precedence. What was your main prognosis and why? Describe how your main prognosis aligns with DSM-5 diagnostic standards and supported by the affected person’s signs.
• Plan: What was your plan for psychotherapy? What was your plan for therapy and administration, together with various therapies? Embrace pharmacologic and nonpharmacologic therapies, various therapies, and follow-up parameters, in addition to a rationale for this therapy and administration plan. Additionally make sure you embrace at the least one well being promotion exercise and one affected person training technique.
• Reflection notes: What would you do in another way with this affected person should you may conduct the session once more? If you’ll be able to comply with up together with your affected person, clarify whether or not these interventions had been profitable and why or why not. If you weren’t capable of conduct a comply with up, focus on what your subsequent intervention can be.
RUBRIC
Detailed Rubric
Title: PRAC_6665_Week7_Assignment2_Rubric
• Listing View
Glorious Good Truthful Poor
zero (zero%) – zero (zero%) zero (zero%) – zero (zero%)
Photograph ID just isn’t displayed. Scholar should treatment this earlier than grade is posted. The scholar just isn’t dressed professionally.
zero (zero%) – zero (zero%) zero (zero%) – zero (zero%)
The video exceeds the Eight-minute time restrict. (Word: Info introduced after Eight minutes won’t be evaluated for grade inclusion.)
Talk about Subjective information:
• Chief grievance
• Historical past of current sickness (HPI)
• Drugs
• Psychotherapy or earlier
psychiatric prognosis
• Pertinent histories and/or ROS 9 (9%) – 10 (10%)
The video precisely and concisely presents the affected person’s subjective grievance, historical past of current sickness, medicines, psychotherapy or earlier psychiatric prognosis, and pertinent histories and/or overview of programs that will inform a differential prognosis. Eight (Eight%) – Eight (Eight%)
The video precisely presents the affected person’s subjective grievance, historical past of current sickness, medicines, psychotherapy or earlier psychiatric prognosis, and pertinent histories and/or overview of programs that will inform a differential prognosis. 7 (7%) – 7 (7%)
The video presents the affected person’s subjective grievance, historical past of current sickness, medicines, psychotherapy or earlier psychiatric prognosis, and pertinent histories and/or overview of programs that will inform a differential prognosis, however is considerably imprecise or comprises minor inaccuracies. zero (zero%) – 6 (6%)
The video presents an incomplete, inaccurate, or unnecessarily detailed/verbose description of the affected person’s subjective grievance, historical past of current sickness, medicines, psychotherapy or earlier psychiatric prognosis, and pertinent histories and/or overview of programs that will inform a differential prognosis. Or subjective documentation is lacking.
Talk about Goal information:
• Bodily examination documentation of programs pertinent to the chief grievance, HPI, and historical past
• Diagnostic outcomes, together with any labs, imaging, or different assessments wanted to develop the differential diagnoses 9 (9%) – 10 (10%)
The video precisely and concisely paperwork the affected person’s bodily examination for pertinent programs. Pertinent diagnostic exams and their outcomes are documented, as relevant. Eight (Eight%) – Eight (Eight%)
The response precisely paperwork the affected person’s bodily examination for pertinent programs. Diagnostic exams and their outcomes are documented, as relevant. 7 (7%) – 7 (7%)
Documentation of the affected person’s bodily examination is considerably imprecise or comprises minor inaccuracies. Diagnostic exams and their outcomes are documented however include inaccuracies. zero (zero%) – 6 (6%)
The response gives incomplete, inaccurate, or unnecessarily detailed/verbose documentation of the affected person’s bodily examination. Programs could have been unnecessarily reviewed, or goal documentation is lacking.
Talk about outcomes of Evaluation:
• Outcomes of the psychological standing examination
• Present a minimal of three potential diagnoses so as of highest to lowest precedence and clarify why you selected them. What was your main prognosis and why? Describe how your main prognosis aligns with DSM-5 diagnostic standards and is supported by the affected person’s signs. 18 (18%) – 20 (20%)
The video precisely paperwork the outcomes of the psychological standing examination.
Video presents at the least three differentials so as of precedence for a differential prognosis of the affected person, and a rationale for his or her choice. Response justifies the first prognosis and the way it aligns with DSM-5 standards. 16 (16%) – 17 (17%)
The video adequately paperwork the outcomes of the psychological standing examination.
Video presents three differentials for the affected person and a rationale for his or her choice. Response adequately justifies the first prognosis and the way it aligns with DSM-5 standards. 14 (14%) – 15 (15%)
The video presents the outcomes of the psychological standing examination, with some vagueness or inaccuracy.
Video presents three differentials for the affected person and a rationale for his or her choice. Response considerably vaguely justifies the first prognosis and the way it aligns with DSM-5 standards. zero (zero%) – 13 (13%)
The response gives an incomplete, inaccurate, or unnecessarily detailed/verbose description of the outcomes of the psychological standing examination and clarification of the differential diagnoses. Or evaluation documentation is lacking.
Talk about therapy Plan:
• A therapy plan for the affected person that addresses psychotherapy; one well being promotion exercise and one affected person training technique; plan for therapy and administration, together with various therapies; pharmacologic and nonpharmacologic therapies, various therapies, and follow-up parameters; and a rationale for the approaches chosen. 18 (18%) – 20 (20%)
The video clearly and concisely outlines an evidence-based therapy plan for the affected person that addresses psychotherapy, well being promotion and affected person training, therapy and administration, pharmacologic and nonpharmacologic therapies, various therapies, and follow-up parameters. A transparent and concise rationale for the therapy approaches really useful is supplied. 16 (16%) – 17 (17%)
The video clearly outlines an applicable therapy plan for the affected person that addresses psychotherapy, well being promotion and affected person training, therapy and administration, pharmacologic and nonpharmacologic therapies, various therapies, and follow-up parameters. A transparent rationale for the therapy approaches really useful is supplied. 14 (14%) – 15 (15%)
The response considerably vaguely or inaccurately outlines a therapy plan for the affected person and gives a rationale for the therapy approaches really useful. zero (zero%) – 13 (13%)
The response doesn’t deal with the prognosis or is lacking parts of the therapy plan.
Replicate on this case. Talk about what you discovered and what you may do in another way. 5 (5%) – 5 (5%)
Reflections are thorough, considerate, and reveal vital pondering. four (four%) – four (four%)
Reflections reveal vital pondering. three.5 (three.5%) – three.5 (three.5%)
Reflections are considerably common or don’t reveal vital pondering. zero (zero%) – three (three%)
Reflections are incomplete, inaccurate, or lacking.
Targeted SOAP Word documentation 18 (18%) – 20 (20%)
The response clearly, precisely, and totally follows the Targeted SOAP Word format to doc the chosen affected person case. 16 (16%) – 17 (17%)
The response precisely follows the Targeted SOAP Word format to doc the chosen affected person case. 14 (14%) – 15 (15%)
The response follows the Targeted SOAP Word format to doc the chosen affected person case, with some vagueness and inaccuracy. zero (zero%) – 13 (13%)
The response incompletely and inaccurately follows the Targeted SOAP Word format to doc the chosen affected person case.
Presentation model 5 (5%) – 5 (5%)
Presentation model is exceptionally clear, skilled, and targeted. four (four%) – four (four%)
Presentation model is evident, skilled, and targeted. three.5 (three.5%) – three.5 (three.5%)
Presentation model is generally clear, skilled, and targeted zero (zero%) – three (three%)
Presentation model is unclear, unprofessional, and/or unfocused.
Whole Factors: 100
Title: PRAC_6665_Week7_Assignment2_Rubric
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