{"id":82691,"date":"2022-07-24T12:31:01","date_gmt":"2022-07-24T12:31:01","guid":{"rendered":"https:\/\/assignmenttutors.net\/blog\/focused-soap-note-for-anxiety-ptsd-and-ocd\/"},"modified":"2023-05-10T09:47:02","modified_gmt":"2023-05-10T09:47:02","slug":"focused-soap-note-for-anxiety-ptsd-and-ocd","status":"publish","type":"post","link":"https:\/\/assignmenttutors.net\/blog\/focused-soap-note-for-anxiety-ptsd-and-ocd\/","title":{"rendered":"Focused soap note for anxiety, ptsd, and ocd"},"content":{"rendered":"<div>\n<p>PLEASE FOLLOW INSTRUCTIONS AND COVER AREAS BELOW TO COMPLETE FOCUSED SOAP NOTE.<\/p>\n<ul>\n<li>Review the Focused SOAP Note template, which you will use to \u00a0complete this Assignment. There is also a Focused SOAP Note Exemplar \u00a0provided as a guide for Assignment expectations.<\/li>\n<li>Review the video,\u00a0<em>Case Study: Dev Cordoba<\/em>. You will use this \u00a0case as the basis of this Assignment. In this video, a faculty member is assessing a mock patient. The patient will be represented \u00a0onscreen as an avatar.<\/li>\n<li>Consider what history would be necessary to collect from this patient.<\/li>\n<li>Consider what interview questions you would need to ask this patient.<\/li>\n<\/ul>\n<h4><strong>The Assignment<\/strong><\/h4>\n<p>Develop a Focused SOAP Note, including your \u00a0differential diagnosis and critical-thinking process to formulate a \u00a0primary diagnosis. Incorporate the following into your responses in the \u00a0template:<\/p>\n<ul>\n<li><strong>Subjective:\u00a0<\/strong>What details did the patient provide regarding \u00a0their chief complaint and symptomology to derive your differential \u00a0diagnosis? What is the duration and severity of their symptoms? How are \u00a0their symptoms impacting their functioning in life?<\/li>\n<li><strong>Objective:\u00a0<\/strong>What observations did you make during the psychiatric assessment?<\/li>\n<li><strong>Assessment:<\/strong>\u00a0Discuss the patient\u00e2\u20ac\u2122s mental status examination \u00a0results. What were your differential diagnoses? Provide a minimum of \u00a0three possible diagnoses with supporting evidence, listed in order from \u00a0highest priority to lowest priority. Compare the\u00a0<em>DSM-5<\/em>\u00a0diagnostic criteria for each differential diagnosis and explain what\u00a0<em>DSM-5<\/em>\u00a0criteria \u00a0rules out the differential diagnosis to find an accurate diagnosis.\u00a0 Explain the critical-thinking process that led you to the primary \u00a0diagnosis you selected. Include pertinent positives and pertinent \u00a0negatives for the specific patient case.<\/li>\n<li><strong>Plan:<\/strong>\u00a0What is your plan for psychotherapy? What is your plan \u00a0for treatment and management, including alternative therapies? Include \u00a0pharmacologic and nonpharmacologic treatments, alternative therapies, \u00a0and follow-up parameters, as well as a rationale for this treatment and \u00a0management plan.\u00a0Also incorporate one health promotion activity and one \u00a0patient education strategy.<\/li>\n<li><strong>Reflection notes:<\/strong>\u00a0What would you do differently with this \u00a0patient if you could conduct the session again?\u00a0Discuss what your next \u00a0intervention would be if you could follow up with this patient.?Also \u00a0include in your reflection a discussion related to legal\/ethical \u00a0considerations (demonstrate critical thinking beyond confidentiality and \u00a0consent for treatment!), health promotion, and disease prevention, \u00a0taking into consideration patient factors (such as age, ethnic group, \u00a0etc.), PMH, and other risk factors (e.g., socioeconomic, cultural \u00a0background, etc.).<\/li>\n<li>Provide at least three evidence-based, peer-reviewed journal \u00a0articles or evidenced-based guidelines that relate to this case to \u00a0support your diagnostics and differential diagnoses. Be sure they are \u00a0current (no more than 5 years old).<\/li>\n<\/ul>\n<p>**\u00a0<strong>Three references<\/strong>\u00a0required<\/p>\n<p>** No plagiarism<\/p>\n<p>Case Study: Dev Cordoba<\/p>\n<p>Program Transcript<\/p>\n<p>[MUSIC PLAYING]<\/p>\n<p>DR. JENNY: Hi there. My name is Dr. Jenny. Can you tell me your name and how old<\/p>\n<p>you are?<\/p>\n<p>DEV CORDOBA: My name is Dev, and I am seven years old.<\/p>\n<p>DR. JENNY: Wonderful. Dev, can you tell me what the month and the date is? And<\/p>\n<p>where are we right now?<\/p>\n<p>DEV CORDOBA: Today is St. Patrick\u2019s Day. It\u2019s March 17th.<\/p>\n<p>DR. JENNY: Do you know where we are?<\/p>\n<p>DEV CORDOBA: We\u2019re at the school.<\/p>\n<p>DR. JENNY: Good. Did your mom tell you why you\u2019re here today to see me?<\/p>\n<p>DEV CORDOBA: She thought you were going to help me be better.<\/p>\n<p>DR. JENNY: Yes, I am here to help you. Have you ever come to see someone like me<\/p>\n<p>before, or talked to someone like me before to help you with your mood?<\/p>\n<p>DEV CORDOBA: No, never.<\/p>\n<p>DR. JENNY: OK. Well, I would like to start with getting to know you a little bit better, if<\/p>\n<p>that\u2019s OK. What do you like to do for fun when you\u2019re at home?<\/p>\n<p>DEV CORDOBA: Oh, I have a dog. His name is Sparky. We play policeman in my<\/p>\n<p>room. And I have LEGOs, and I could build something if you want.<\/p>\n<p>DR. JENNY: I would love to see what you build with your LEGOs. Maybe you can bring<\/p>\n<p>that in for me next appointment. Who lives in your home?<\/p>\n<p>DEV CORDOBA: My mom and my baby brother and Sparky.<\/p>\n<p>DR. JENNY: Do you help your mom with your brother?<\/p>\n<p>DEV CORDOBA: No. His breath smells like bad milk all the time. [CHUCKLES] And he<\/p>\n<p>cries a lot, and my mom spends more time with him.<\/p>\n<p>DR. JENNY: So how do you feel most of the time? Do you feel sad or worried or mad or<\/p>\n<p>happy?<\/p>\n<p>DEV CORDOBA: Worried.<\/p>\n<p>DR. JENNY: What types of things do you worry about?<\/p>\n<p>Case Study: Dev Cordoba<\/p>\n<p>DEV CORDOBA: I don\u2019t know, just everything. I don\u2019t know.<\/p>\n<p>DR. JENNY: OK. So your mom tells me you also have a lot of bad dreams. Can you tell<\/p>\n<p>me a little more about your bad dreams, like maybe what they\u2019re about, how many<\/p>\n<p>nights you might have them?<\/p>\n<p>DEV CORDOBA: I dream a lot that I\u2019m lost, that I can\u2019t find my mom or my little brother.<\/p>\n<p>They seem like they happen almost every night, but maybe not some nights.<\/p>\n<p>DR. JENNY: Now that must feel horrible. Have you ever been lost before when maybe<\/p>\n<p>you weren\u2019t asleep?<\/p>\n<p>DEV CORDOBA: Oh, no. No. And I don\u2019t like the dark. My mom puts me in a night light<\/p>\n<p>with the door open, so I know she\u2019s really there.<\/p>\n<p>DR. JENNY: That seems like that probably would help. Do you like to go to school? Or<\/p>\n<p>would you rather not go?<\/p>\n<p>DEV CORDOBA: I worry about by mom and brother when I\u2019m at school. All I can think<\/p>\n<p>about is what they\u2019re doing, and if they\u2019re OK. And besides, nobody likes me there.<\/p>\n<p>They call me Mr. Smelly.<\/p>\n<p>DR. JENNY: Well. That\u2019s not nice at all. Why do you feel they call you names?<\/p>\n<p>DEV CORDOBA: I don\u2019t know. But my mom says it\u2019s because I won\u2019t take my baths.<\/p>\n<p>[SIGHS] She tells me to, and it\u2013 and I have night accidents.<\/p>\n<p>DR. JENNY: Oh, how does that make you feel?<\/p>\n<p>DEV CORDOBA: Sad and really bad. They don\u2019t know how it feels for their daddy to<\/p>\n<p>never come home. What if my mom doesn\u2019t come home too?<\/p>\n<p>DR. JENNY: Yes, you seem to worry about that a lot. Does this worry stop you from<\/p>\n<p>being able to learn in school?<\/p>\n<p>DEV CORDOBA: Well, [SIGHS] my teacher is, all the time, telling me to sit down and<\/p>\n<p>focus. And I get in trouble for [SIGHS] looking out the window. And she moved my chair<\/p>\n<p>beside her desk, but I don\u2019t mind because Billy leaves me alone now.<\/p>\n<p>DR. JENNY: Billy. Have you ever hit Billy or anyone else?<\/p>\n<p>DEV CORDOBA: No, but I did throw my book at him.<\/p>\n<p>DR. JENNY: Hmm.<\/p>\n<p>DEV CORDOBA: [CHUCKLES]<\/p>\n<p>Case Study: Dev Cordoba<\/p>\n<p>\u00a9 2021 Walden University, LLC 3<\/p>\n<p>DR. JENNY: What about yourself? Have you ever hit yourself or thought about doing<\/p>\n<p>something to hurt yourself?<\/p>\n<p>DEV CORDOBA: No.<\/p>\n<p>DR. JENNY: OK. Well, Dev, I would like to talk to your mom now. We\u2019re going to work<\/p>\n<p>together, and we\u2019re going to help you feel happier, less worried, and be able to enjoy<\/p>\n<p>school more. Is that OK?<\/p>\n<p>DEV CORDOBA: Yes. Thank you.<\/p>\n<p>MISS CORDOBA: Hi.<\/p>\n<p>DR. JENNY: Thank you, Miss Cordoba, for bringing in Dev. I feel we can help him. So<\/p>\n<p>tell me, what is your main concerns for Dev?<\/p>\n<p>MISS CORDOBA: [SIGHS] Well, he just seems so anxious and worried all the time, silly<\/p>\n<p>things like I\u2019m going to die, or I won\u2019t pick him up from school. He says I love his brother<\/p>\n<p>more than him. He\u2019ll throw things around the house, and gets in trouble at school for<\/p>\n<p>throwing things.<\/p>\n<p>He has a difficult time going to sleep. He wants his lights on, doors open, gets up<\/p>\n<p>frequently. And he\u2019s all the time wanting to come home from school, claims stomach<\/p>\n<p>aches, and headaches almost daily. He won\u2019t eat. He\u2019s lost three pounds in the past<\/p>\n<p>three weeks. Our pediatrician sent us to you because he doesn\u2019t believe anything is<\/p>\n<p>physically wrong.<\/p>\n<p>Oh, and I almost forgot. He still wets the bed at night. [SIGHS] We\u2019ve tried everything.<\/p>\n<p>His pediatrician did give him DDVAP, but it doesn\u2019t seem to help.<\/p>\n<p>DR. JENNY: Hmm. OK. Can you tell me, any blood relatives have any mental health or<\/p>\n<p>substance use issues?<\/p>\n<p>MISS CORDOBA: No, not really.<\/p>\n<p>DR. JENNY: What about his father? He said that he never came home?<\/p>\n<p>MISS CORDOBA: Oh, yes. His father was deployed with the military when Dev was<\/p>\n<p>five. I told Dev he was on vacation. I didn\u2019t know what to tell him. I thought he was too<\/p>\n<p>young to know about war. And his father was killed, so Dev still doesn\u2019t understand that<\/p>\n<p>his father didn\u2019t just leave him. [SIGHS] I just feel so guilty that all of this is my fault.<\/p>\n<p>DR. JENNY: Miss Cordoba, you did the right thing by bringing in Dev. We can help you<\/p>\n<p>with him.<\/p>\n<p>Attached below is the template to use and an example of how to answer the questions<\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>PLEASE FOLLOW INSTRUCTIONS AND COVER AREAS BELOW TO COMPLETE FOCUSED SOAP NOTE. Review the Focused SOAP Note template, which you will use to \u00a0complete this Assignment. There is also a Focused SOAP Note Exemplar \u00a0provided as a guide for Assignment expectations. Review the video,\u00a0Case Study: Dev Cordoba. You will use this \u00a0case as the basis [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[41],"tags":[],"class_list":["post-82691","post","type-post","status-publish","format-standard","hentry","category-nursing-healthcare-medicine-nursing"],"_links":{"self":[{"href":"https:\/\/assignmenttutors.net\/blog\/wp-json\/wp\/v2\/posts\/82691","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/assignmenttutors.net\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/assignmenttutors.net\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/assignmenttutors.net\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/assignmenttutors.net\/blog\/wp-json\/wp\/v2\/comments?post=82691"}],"version-history":[{"count":1,"href":"https:\/\/assignmenttutors.net\/blog\/wp-json\/wp\/v2\/posts\/82691\/revisions"}],"predecessor-version":[{"id":122658,"href":"https:\/\/assignmenttutors.net\/blog\/wp-json\/wp\/v2\/posts\/82691\/revisions\/122658"}],"wp:attachment":[{"href":"https:\/\/assignmenttutors.net\/blog\/wp-json\/wp\/v2\/media?parent=82691"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/assignmenttutors.net\/blog\/wp-json\/wp\/v2\/categories?post=82691"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/assignmenttutors.net\/blog\/wp-json\/wp\/v2\/tags?post=82691"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}