Review the Learning Resources. Consider the insights provided about assessing and diagnosing anxiety, obsessive compulsive, and trauma-related disorders.
Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
Review the video, Case Study: Dev Cordoba. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
Consider what history would be necessary to collect from this patient.Think about a comprehensive assessment and compare the information
Consider what interview questions you would need to ask this patient.
Develop a Focused SOAP Note,
Include your differential diagnosis and critical-thinking process to formulate a primary diagnosis Think of the many diagnoses for this client and list them in order of significance
Incorporate and list questions to ask the client in your template responses.
The Rubric Example.This is only the SUBJECTIVE part of the RUBRIC!!!! Follow for Maximum Points.
Create documentation in the Focused SOAP Note Template about your assigned patient.
In the Subjective section, provide:
Chief complaint
History of present illness (HPI)
Past psychiatric history
Medication trials and current medications
Psychotherapy or previous psychiatric diagnosis
Pertinent substance use, family psychiatric/substance use, social, and medical history
Allergies
ROS
Subjective:
What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis?
What is the duration and severity of their symptoms?
How are their symptoms impacting their functioning in life?
Objective:
What observations did you make during the psychiatric assessment?
Assessment:
Discuss the patients mental status examination results.
What were your differential diagnoses?
Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority.
Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 TR criteria rules out the differential diagnosis to find an accurate diagnosis.
Explain the critical-thinking process that led you to the primary diagnosis you selected.
Include pertinent positives and pertinent negatives for the specific patient case.
Plan:
What is your plan for psychotherapy?
What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, follow-up parameters, and rationale for this treatment and management plan. Also, incorporate one health promotion activity and one patient education strategy.
Reflection notes:
What would you do differently with this patient if you could conduct the session again?
Discuss what your next intervention would be if you could follow up with this patient.
Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion, and disease prevention, taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnosis (no more than five years old).
