Focused SOAP Note And Patient Case Presentation
Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you examined during the last 4 weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.
Subjective
The patient is a 24-year-old female who was seen today for initial evaluation via video session with her consent. She is diagnosed with adjustment disorder. The patient stated, “I really didn’t want therapy, it is my mom who wants us to see therapy together”. She stated that she does not have a relationship with her mother. She stated, “I agreed to see a therapist because that is the only way to communicate with my mom”. She said that her mother initiated for them to come to CLAY for therapy. She said that her mother has lots of issues, that she is overbearing. The patient said that her mother is very controlling and emotionally discharges when she tries talking to her. The patient agrees to do family therapy with her mother. The patient stated that she is not on any medication currently, but stated, “I smoke marijuana a lot regularly every day”. The patient stated that she tried to commit suicide at age 13 because she took a whole bottle of Adderall because her mother was pressing her to be taking it, but she went to school, and she told the teacher what she did and the teacher to her to the hospital. She said that she stayed in the psychiatric hospital for a week. The patient stated that there is a history of family mental illness in both the father and mother’s sides of the family. The patient stated that her parents divorced when she was 7 years old. She said that her father was very abusive. She said that she lived with her mother until she turned 20 years old and moved out of the house. She stated, “I’m currently living with my ex-boyfriend, and trying to find a place for myself”. She said she was bullied in middle school, but for high school, her mother was her bully. The patient said that she graduated high school and worked as a property manager.
Objective:
The patient is alert and oriented x 4, to person, place, time, and situation. She appeared very neat and clean. Her eye contact is very intense. She is cooperative, her mood is euphoric, her affect is labile, the thought process is intact, and goal directed. Fair insight and judgment, cognitively intact. The patient is not on any medication currently. She reports tried to commit suicide when she was 13 years old by taking a whole bottle of Adderall with intention of committing suicide but was taken to the hospital on time by her teacher after she her teacher and she was hospitalized for one week in the psychiatric hospital. The patient denies visual or auditory hallucination currently. She denies suicidal or homicidal ideation presently.
Assessment:
Diagnosis: Adjustment Disorder. The rating scale for PHQ-9 is 6/27 and she has little or no anxiety or depression. The patient is a 24-year-old African American female, alert, and oriented x 4, to person, place, time, and situation. She was seen today for initial evaluation via video conference with consent. She is seeking family therapy to facilitate a healthy adult relationship with her mother. The patient is not currently taking any medication. This Patient is referred to individual therapy along with family therapy with the mother to help facilitate building their relationship. The patient stated that she is already seeing a therapist and that she is willing to commit to this new therapy with her mother, and she will be seeing each on different days. The patient will be followed-up in 4 weeks. The patient stated that she does not exercise, her eating is not that great, and her appetite fluctuates. The patient is advised/encouraged to commit to exercise to increase her natural serotonin, increase her overall immunity and good health. Also, she is encouraged to focus on positive coping skills like exercise, taking a walk, finding an activity that she enjoys, and try to surround herself with positive people. She is encouraged to slow down on cannabis consumption. The patient agreed and verbalized understanding. The patient denied visual or auditory hallucination. She denied suicidal or homicidal ideation currently. She is instructed to call 911 immediately if she experiences suicidal or homicidal ideation, and she verbalized understanding.
Plan of care: The patient will have increased adjustment to her mother in 90 days. The patient has been referred to individual psychotherapy along with family therapy with her mother. The patient was instructed to exercise daily to increase her overall good health, immunity, and natural serotonin. She is encouraged to start cutting down on cannabis intake. She agreed and verbalized understanding. Follow-up in 4 weeks. Call 911 if experiencing suicidal or homicidal. The patient verbalized understanding.
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