Select a patient of any age (either a child or an adult) that you examined during the last 3 weeks.
Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.
PatientPatient is a 28-year-old male who walked into therapy due to substance abuse disorder. It is using alcohol and Heroin. Patient has history of depression. Pt was cooperative with staff. Patient states it stayed sober for one year and now he relapsed again by heroin/alcohol. He feels so lonely after his girlfriend cheated on him with his best friend. Patient was educated of how to cope with depression. At this visit, Cognitive Behavioral Therapy (CBT) techniques were used. Patient will see therapist every week for group cognitive behavioral therapy for 3 months.
