{"id":17679,"date":"2024-08-07T07:37:31","date_gmt":"2024-08-07T07:37:31","guid":{"rendered":"https:\/\/essaybishops.com\/help\/unit-4-assignment-soap-note-case-study-2\/"},"modified":"2024-08-07T07:37:31","modified_gmt":"2024-08-07T07:37:31","slug":"unit-4-assignment-soap-note-case-study-2","status":"publish","type":"post","link":"https:\/\/www.colapapers.com\/uk\/unit-4-assignment-soap-note-case-study-2\/","title":{"rendered":"Unit 4 Assignment SOAP NOTE Case Study 2"},"content":{"rendered":"<p>Unit 4 Assignment SOAP NOTE\/Case Study 2<\/p>\n<p>SOAP Note<\/p>\n<p>Patient Name: G.D. MRN: XXX Date of Service: 01-27-2020 Start Time: 10:00 AM End Time: 10:54 AM Billing Code(s): 90213, 90836 Accompanied by: Brother CC: Follow-up appointment for counseling after discharge from inpatient psychiatric unit 2 days ago<\/p>\n<p>Subjective (S): Mr. Davis reports generally improved depressive and anxiety symptoms but still feels down at times. He states he is sleeping better, achieving 7-8 hours of restful sleep nightly. He finds the medication somewhat helpful without noticeable side effects. Mr. Davis believes the coping mechanisms learned during inpatient care have been beneficial. He denies current suicidal ideation or plans and reports no access to prescription medications besides fluoxetine.<\/p>\n<p>Objective (O): Vitals: T 98.4, P 82, R 16, BP 122\/78 PE: Not performed during this psychotherapy session Labs: CBC, lytes, and TSH all within normal limits Psychiatric Clinical Tests: BAI = 34<\/p>\n<p>Mental Status Examination: Mr. Davis presented disheveled and unkempt, wearing dirty clothes. He appeared younger than his stated age. During the interview, he was attentive and calm but impatient. He reported feeling it was his &#8220;best day ever&#8221; due to a decision to start his own company. His affect was labile, fluctuating with speech content. Speech was loud and pressured at times, quickly regaining composure. He exhibited flight of ideas and loosening of associations, abruptly shifting topics. Mr. Davis expressed grandiose delusions regarding sexual and athletic performance. He denied auditory hallucinations and displayed orientation to time and place. He denied suicidal and homicidal ideation but refused memory or intellectual testing. Reliability, judgment, and insight were impaired.<\/p>\n<p>Assessment (A): Differential Diagnoses:<\/p>\n<p>Major Depressive Disorder, recurrent, without psychotic features (F33.4)<\/p>\n<p>Bipolar Disorder with Psychotic Features (F31.6)<\/p>\n<p>Schizophrenia (F20.0)<\/p>\n<p>Definitive Diagnosis: Major Depressive Disorder, recurrent, without psychotic features (F33.4) Generalized Anxiety Disorder (F41.1)<\/p>\n<p>Plan (P):<\/p>\n<p>Pharmacological Treatment:<\/p>\n<p>Continue Fluoxetine, increasing dose to 20mg daily<\/p>\n<p>Psychotherapy:<\/p>\n<p>Continue outpatient counseling: partial inpatient program with individual and group sessions<\/p>\n<p>Modality: Cognitive Behavioral Therapy (CBT)<\/p>\n<p>Education:<\/p>\n<p>Discussed smoking cessation options<\/p>\n<p>Reviewed medication side effects and importance of adherence<\/p>\n<p>Follow-up:<\/p>\n<p>Schedule appointment in one week or earlier if depressive symptoms worsen<\/p>\n<p>Referrals:<\/p>\n<p>None at this time<\/p>\n<p>Summary of Warning Signs and Treatment Plan Rationale:<\/p>\n<p>Warning Signs of Suicidality: While Mr. Davis denies current suicidal ideation, several concerning factors warrant close monitoring:<\/p>\n<p>Recent discharge from inpatient psychiatric care following a suicide attempt<\/p>\n<p>Ongoing depressive symptoms despite some improvement<\/p>\n<p>Presence of psychotic features (grandiose delusions, flight of ideas)<\/p>\n<p>Impaired judgment and insight<\/p>\n<p>High anxiety levels (BAI score of 34)<\/p>\n<p>Treatment Plan Rationale: The treatment plan addresses Mr. Davis&#8217;s complex presentation of Major Depressive Disorder with psychotic features and comorbid anxiety. The multifaceted approach includes:<\/p>\n<p>Medication Management: Increasing fluoxetine dosage aims to further alleviate depressive and anxiety symptoms. Fluoxetine, a selective serotonin reuptake inhibitor (SSRI), has shown efficacy in treating both depression and anxiety (Cipriani et al., 2018).<\/p>\n<p>Continued Partial Inpatient Program: This structured environment provides intensive support during the critical post-discharge period, reducing suicide risk and allowing for close monitoring of symptoms (Nordentoft et al., 2015).<\/p>\n<p>Cognitive Behavioral Therapy (CBT): CBT is an evidence-based intervention for depression and anxiety, helping patients identify and modify negative thought patterns and behaviors (Beck &#038; Bredemeier, 2016).<\/p>\n<p>Regular Follow-up: Weekly appointments allow for close monitoring of symptom progression and medication efficacy, crucial for suicide prevention and early intervention if needed (American Psychiatric Association, 2013).<\/p>\n<p>Psychoeducation: Discussing medication adherence and smoking cessation addresses potential barriers to recovery and promotes overall health, which can positively impact mental health outcomes (NICE, 2018).<\/p>\n<p>This comprehensive approach targets Mr. Davis&#8217;s depressive symptoms, anxiety, and psychotic features while maintaining vigilance for any signs of increased suicide risk. The treatment plan&#8217;s flexibility allows for adjustments based on his response to interventions.<\/p>\n<p>References:<\/p>\n<p>American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing.<\/p>\n<p>Beck, A. T., &#038; Bredemeier, K. (2016). A unified model of depression: Integrating clinical, cognitive, biological, and evolutionary perspectives. Clinical Psychological Science, 4(4), 596-619.<\/p>\n<p>Cipriani, A., Furukawa, T. A., Salanti, G., Chaimani, A., Atkinson, L. Z., Ogawa, Y., &#8230; &#038; Geddes, J. R. (2018). Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. The Lancet, 391(10128), 1357-1366.<\/p>\n<p>National Institute for Health and Care Excellence (NICE). (2018). Depression in adults: recognition and management. NICE guideline [NG56]. London: NICE.<\/p>\n<p>Nordentoft, M., Wahlbeck, K., H\u00e4llgren, J., Westman, J., \u00d6sby, U., Alinaghizadeh, H., &#8230; &#038; Laursen, T. M. (2015). Excess mortality, causes of death and life expectancy in 270,770 patients with recent onset of mental disorders in Denmark, Finland and Sweden. PloS one, 10(1), e0113296.<\/p>\n<p>Keywords: Major Depressive Disorder, Suicide Risk Assessment, Cognitive Behavioral Therapy<\/p>\n<p>========================================<\/p>\n<p>SOAP note + 1 page summary that highlights the warning signs of suicidality in the patient and why you chose the treatment plan you choose in your SOAP Note. <\/p>\n<p>Review the video case: Suicide assessment of Client with initially Subtle Warning Signs of Suicide<br \/>\n<iframe loading=\"lazy\" title=\"Suicide Assessment of Client with Initially Subtle Warning Signs of Suicide\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/P2a9102jifM?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe><br \/>\nComplete a SOAP Note as if you were the psychotherapist in the video. Then write a one page summary that highlights the warning signs of suicidality in the patient and why you chose the treatment plan you choose in your SOAP Note.<br \/>\nSOAP Template:<br \/>\nPatient Name:  XXX<br \/>\nMRN: XXX<\/p>\n<p>Date of Service:  \t01-27-2020<\/p>\n<p>Start Time:  \t\t10:00\t\tEnd Time:    \t\t10:54<\/p>\n<p>Billing Code(s): \t90213, 90836<br \/>\n(be sure you include strictly psychotherapy codes or both E&#038;M and add on psychotherapy codes if prescribing provider visit)<\/p>\n<p>Accompanied by:  \tBrother<\/p>\n<p>CC: follow-up appt. for counseling after discharge from inpatient psychiatric unit 2 days ago<\/p>\n<p>HPI: 1 week from inpatient care to current partial inpatient care daily individual psychotherapy session and extended daily group sessions<\/p>\n<p>S- Patient states that he generally has been doing well with depressive and anxiety symptoms improved but he still feels down at times. He states he is sleeping better, achieving 7-8 hours of restful sleep each night. He states he feels the medication is helping somewhat and without any noticeable side-effects.<br \/>\nCrisis Issues:  He states he has no suicide plan and has not thought about suicide since the recent attempt. He states has no access to prescription medications, other than the fluoxetine. He believes the classes he participated in while inpatient have helped him with coping mechanisms.<br \/>\n\tReviewed Allergies: NKA<br \/>\n\tCurrent Medications: Fluoxetine 10mg daily<br \/>\n\tROS: no complaints<\/p>\n<p>O-<br \/>\nVitals: T 98.4, P 82, R 16, BP 122\/78<br \/>\nPE: (not always required and performed, especially in psychotherapy only visits)<br \/>\nHeart- RRR, no murmurs, no gallops<br \/>\nLungs- CTA bilaterally<br \/>\nSkin- no lesions or rashes<br \/>\nLabs: CBC, lytes, and TSH all within normal limits <\/p>\n<p>Results of any Psychiatric Clinical Tests: BAI=34<\/p>\n<p>MSE:<br \/>\nGary Davis, a 36-year-old white male, was disheveled and unkempt on presentation to the outpatient office. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age. During the interview, he was attentive and calm. He was impatient, but polite in his interactions with this examiner. Mr. Davis reported that today was the best day of his life, because he had decided he was going to be better and start his own company. His affect was labile, but appropriate to the content of his speech (i.e., he became tearful when reporting he had \u201cbogeyed number 15\u201d in gold yesterday). His speech was loud, pressured at times then he would quickly gain composure to a more neutral tone. He exhibited loosening of associations and flight of ideas; he intermittently and unpredictably shifted the topic of conversation from golf, to the mating habits of geese, to the likelihood of extraterrestrial life. Mr. Davis described grandiose delusions regarding his sexual and athletic performance. He reported no auditory hallucinations. He was oriented to time and place. He denied suicidal and homicidal ideation. He refused to participate in intellectual- or memory-related portions of the examination. Reliability, judgment, and insight were impaired.<\/p>\n<p>A &#8211; with (ICD-10 code)<br \/>\nDifferential Diagnoses:<br \/>\n1. choose 3 differential diagnoses<br \/>\n2.<br \/>\n3.<br \/>\nDefinitive Diagnosis:<br \/>\nMajor Depressive Disorder, recurrent, without psychotic features F33.4<br \/>\nGeneralized Anxiety Disorder F41.1<\/p>\n<p>P- Continue Fluoxetine increasing dose to 20mg. <\/p>\n<p>Continue outpatient counseling: partial inpatient program continued with individual and group sessions<\/p>\n<p>Non-pharmacological Tx: Psychotherapy Modality used:  CBT<br \/>\nPharmacological Tx: (be specific and give detailed Rx information)<br \/>\nEducation: discussed smoking cessation<br \/>\nReviewed medication side effects and adherence importance<br \/>\nFollow-up:  in one week or earlier if any depressive symptoms worsen.<br \/>\nReferrals: none at this time<\/p>\n<p>Grading Rubic:<br \/>\nAssignment Criteria\tLevel III\tLevel II\tLevel I\tNot Present<br \/>\nCriteria 1\tLevel III Max Points<br \/>\nPoints: 8\tLevel II Max Points<br \/>\nPoints: 6.4\tLevel I Max Points<br \/>\nPoints: 4.8\t0 Points<br \/>\nSubjective Information<br \/>\n\t\u25cf\tComplete and concise summary of pertinent information. \t\u25cf\tWell organized; partial but accurate summary of pertinent information (>80%).\t\u25cf\tPoorly organized and\/or limited summary of pertinent information (50%-80%); information other than \u201cS\u201d provided.\t\u25cf\tDoes not meet the criteria<br \/>\nAssignment Criteria\tLevel III\tLevel II\tLevel I\tNot Present<br \/>\nCriteria 2\tLevel III Max Points<br \/>\nPoints: 8\tLevel II Max Points<br \/>\nPoints: 6.4\tLevel I Max Points<br \/>\nPoints: 4.8\t0 Points<br \/>\nObjective Information<br \/>\n\t\u25cf\tComplete and concise summary of pertinent information.\t\u25cf\tPartial but accurate summary of pertinent information (>80%).\t\u25cf\tPoorly organized and\/or limited summary of pertinent information (50%-80%); information other than \u201cO\u201d provided.\t\u25cf\tDoes not meet the criteria<br \/>\nAssignment Criteria\tLevel III\tLevel II\tLevel I\tNot Present<br \/>\nCriteria 3\tLevel III Max Points<br \/>\nPoints: 8\tLevel II Max Points<br \/>\nPoints: 6.4\tLevel I Max Points<br \/>\nPoints: 4.8\t0 Points<br \/>\nAssessment: Problem Identification and Prioritization\t\u25cf\tComplete problem list generated and rationally prioritized; no extraneous information or issues listed. <\/p>\n<p>\t\u25cf\tMost problems are identified and rationally prioritized, including the \u201cmain\u201d problem for the case (>80%). \t\u25cf\tSome problems are identified (50%-80%); incomplete or inappropriate problem prioritization; includes nonexistent problems or extraneous information included.\t\u25cf\tDoes not meet the criteria<br \/>\nCriteria 4\tLevel III Max Points<br \/>\nPoints: 8\tLevel II Max Points<br \/>\nPoints: 6.4\tLevel I Max Points<br \/>\nPoints: 4.8\t0 Points<br \/>\nAssessment: Assessment of Current Psychiatric &#038; Medical Condition(s) or Drug Therapy-related Problem \t\u25cf\tAn optimal and thorough assessment is present for each problem\t\u25cf\tAn assessment is present for each problem listed but not optimal\t\u25cf\tAssessment is present for 50-80% of problems\t\u25cf\tDoes not meet the criteria<\/p>\n<p>Assignment Criteria\tLevel III\tLevel II\tLevel I\tNot Present<br \/>\nCriteria 5\tLevel III Max Points<br \/>\nPoints: 6\tLevel II Max Points<br \/>\nPoints: 4.8\tLevel I Max Points<br \/>\nPoints: 3.6\t0 Points<br \/>\nAssessment: Treatment Goals\t\u25cf\tAppropriate and relevant therapeutic goals for each identified problem. \t\u25cf\tAppropriate therapeutic goals for most identified problems (>80%). \t\u25cf\tAppropriate therapeutic goals for a few identified problems (50%-80%). \t\u25cf\tLess than 50% of problems have appropriate therapeutic goals.<br \/>\nAssignment Criteria\tLevel III\tLevel II\tLevel I\tNot Present<br \/>\nCriteria 6\tLevel III Max Points<br \/>\nPoints: 6\tLevel II Max Points<br \/>\nPoints: 4.8\tLevel I Max Points<br \/>\nPoints: 3.6\t0 Points<br \/>\nPlan: Treatment Plan\t\u25cf\tSpecific, appropriate and justified recommendations (including drug name, strength, route, frequency, and duration of therapy) for each identified problem are included. \t\u25cf\tIncludes most of the requirements for each identified problem (>80%). \t\u25cf\tIncomplete and\/or inappropriate for a few identified problems (50%-80%); information other than \u201cP\u201d provided.\t\u25cf\tLess than 50% of problems have an appropriate and complete treatment plan.<br \/>\nCriteria 7\tLevel III Max Points<br \/>\nPoints: 6\tLevel II Max Points<br \/>\nPoints: 4.8\tLevel I Max Points<br \/>\nPoints: 3.6\t0 Points<br \/>\nPlan: Counseling, Referral, Monitoring &#038;  Follow-up\t\u25cf\tSpecific patient education points, monitoring parameters, follow-up plan and (where applicable) referral plan for each identified problem. \t\u25cf\tPatient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for >80% of identified problems.\t\u25cf\tPatient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for a few identified problems (50%-80%).\t\u25cf\tLess than 50% of problems include appropriate counseling, monitoring, referral and\/or follow-up plan.<br \/>\nMaximum Total Points\t50\t40\t30<br \/>\nMinimum Total Points\t41 points minimum\t31 points minimum\t1 point minimum<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Unit 4 Assignment SOAP NOTE\/Case Study 2 SOAP Note Patient Name: G.D. MRN: XXX Date of Service: 01-27-2020 Start Time: 10:00 AM End Time: 10:54 AM Billing Code(s): 90213, 90836 Accompanied by: Brother CC: Follow-up appointment for counseling after discharge from inpatient psychiatric unit 2 days ago Subjective (S): Mr. Davis reports generally improved depressive [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[6289,6288],"tags":[3952,6291,6290,3643,2392],"class_list":["post-17679","post","type-post","status-publish","format-standard","hentry","category-healthcare","category-write-my-paper","tag-masters-essays","tag-medical-essays","tag-need-help","tag-research-topics","tag-write-my-thesis"],"_links":{"self":[{"href":"https:\/\/www.colapapers.com\/uk\/wp-json\/wp\/v2\/posts\/17679","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.colapapers.com\/uk\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.colapapers.com\/uk\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/uk\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/uk\/wp-json\/wp\/v2\/comments?post=17679"}],"version-history":[{"count":0,"href":"https:\/\/www.colapapers.com\/uk\/wp-json\/wp\/v2\/posts\/17679\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.colapapers.com\/uk\/wp-json\/wp\/v2\/media?parent=17679"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.colapapers.com\/uk\/wp-json\/wp\/v2\/categories?post=17679"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.colapapers.com\/uk\/wp-json\/wp\/v2\/tags?post=17679"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}