Focused SOAP Note : Schizophrenia

Assignment 2: Focused
SOAP Note and Patient Case Presentation
Schizophrenia

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.
Select an adult
patient that you examined during the last 4 weeks who presented
with a disorder other than the disorder present in your Week 3
Case Presentation. (Disorder selected is Schizophrenia)
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.

Include at least five
scholarly resources to support your assessment, diagnosis, and treatment
planning.

Present the full complex
case study. Include chief complaint; history of present illness; any
pertinent past psychiatric, substance use, medical, social, family
history; most recent mental status exam; current psychiatric diagnosis
including differentials that were ruled out; and plan for treatment and
management.
Report normal diagnostic
results as the name of the test and “normal” (rather than specific value).
Abnormal results should be reported as a specific value.

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 patient
mental status examination results. What were your differential diagnoses?
Provide a minimum of three possible diagnoses and why you chose them.
List them from highest priority to lowest priority. What was your primary
diagnosis, and why? Describe how your primary diagnosis aligns
with DSM-5 diagnostic criteria and supported by the
patient’s symptoms.
Plan: What was your plan
for psychotherapy? What was your plan for treatment and management,
including alternative therapies? Include pharmacologic and
nonpharmacologic treatments, alternative therapies, and follow-up
parameters, as well as a rationale for this treatment and management
plan. Be sure to include at least 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
over? If you are able to follow up with your patient, explain
whether these interventions were successful and why or why not. If you
were not able to conduct a follow up, discuss what your next intervention
would be.

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