Focused SOAP Evaluation
Case Study transcript and video are in the attachments.
Develop a Focused SOAP Note, including a differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into the responses in the template:
Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive at the differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective: What observations were made during the psychiatric assessment?
Assessment: Discuss the patient’s mental status examination results. What were the 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-TR 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 to the primary diagnosis selected. Include pertinent positives and pertinent negatives for the specific patient case.
Plan: What is the plan for psychotherapy? What is the 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. Also incorporate one health promotion activity and one patient education strategy.
Reflection notes: What could be done differently with this patient if conducting the session again? Discuss what the next intervention would be if following up with this patient. Also include in the 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 the diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).