HSV340 Case Management Soap Note Referral

Hsv340case Managementhsv340 Case Managementsoap Note Referral Ass

For this assignment, you will be writing a case note and referral summary based on the case of Greg. After watching the Chapter 6 Helper Studio video in Mindtap, you will assume the role of an intake interviewer for 211, a resource referral source, and draft a case note using the SOAP note format based on your meeting with Greg. Once your case note is completed, you will prepare a referral summary for one service provider. This referral summary should be brief and should also follow the guidelines of confidentiality. When preparing your summary, determine what information is necessary to share in order to make the referral.

Paper For Above instruction

Introduction

The purpose of this paper is twofold: to develop a comprehensive SOAP note based on an interview with Greg and to create an effective referral summary for an appropriate service provider. The process involves detailed documentation of Greg's presenting issues, personal history, and current circumstances, followed by a strategic referral that addresses his needs while maintaining confidentiality. The approach reflects best practices in case management, emphasizing clarity, objectivity, and relevance in documentation and referrals.

Subjective Data

Greg reports feeling overwhelmed and anxious over the past few months. He describes persistent feelings of stress related to his financial situation and recent job instability. Greg mentions experiencing difficulty sleeping, occasional headaches, and feelings of hopelessness. He reports struggling to maintain his daily routine and feeling isolated from friends and family. Greg states that he has tried to manage his stress through sometimes increased alcohol consumption but finds it ineffective and wants to find healthier coping mechanisms. He denies any suicidal thoughts but admits he's feeling generally overwhelmed and unsure about his future. Greg also mentions that he has a history of mild depression during his teenage years, but he has not sought treatment for it since then.

Objective Data

During the interview, Greg appeared anxious but cooperative. He was appropriately dressed, with no visible signs of self-harm or neglect. His speech was coherent and relevant. Vital signs were not measured during this session, but Greg appeared alert and oriented. Physical appearance was consistent with his stated personal history, and no physical abnormalities were observed. His affect was subdued, and he expressed feelings of frustration and sadness. There were no signs of intoxication, and cognitive functions appeared intact based on his responses. No observable physical health issues were detected during the interview.

Assessment

Greg’s presentation suggests symptoms consistent with generalized anxiety disorder and situational depression, primarily linked to recent life stressors such as job instability and financial concerns. His history of mild depression adds context to his current emotional state. The unhealthy coping mechanism of increased alcohol use indicates a need for targeted intervention to develop healthier stress management strategies. Given the subjective and objective data, it is important to monitor his mental health status and explore the possibility of further evaluation or treatment options to prevent escalation of symptoms.

Plan

1. Develop a safety plan, emphasizing the importance of utilizing coping skills and support systems. 2. Recommend that Greg consider engaging with a licensed mental health counselor for therapy aimed at managing anxiety and depression. 3. Provide information about local support groups or community resources that address stress management and mental health support. 4. Encourage lifestyle modifications, including regular exercise, improved sleep hygiene, and reduction of alcohol intake. 5. Schedule follow-up to monitor progress and reassess needs, considering medication consultation if symptoms persist or worsen. 6. Offer psychoeducation about stress and mental health to increase awareness and reduce stigma.

Referral Summary

Client Name: Greg Johnson, age 32, male. Greg presents with symptoms of increased anxiety, depressive feelings, and stress related to recent personal and financial challenges. His history includes mild depression during adolescence, with current exacerbation linked to ongoing life stressors. Referred to a licensed mental health counselor specializing in anxiety and depression management. The referral includes a summary of his current symptoms, personal history, and the need for therapeutic intervention to develop coping skills and improve mental health stability. Confidentiality has been maintained, and only necessary information has been shared to facilitate appropriate treatment engagement.

References

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
• Bryant, R. A., & Harvey, A. G. (2019). Posttraumatic stress disorder: A comprehensive review. In M. J. Friedman, T. M. Keane, & P. A. Resick (Eds.), Handbook of PTSD: Science and practice (pp. 135–154). Guilford Press.
• Mayo Clinic Staff. (2022). Anxiety disorder. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/anxiety/symptoms-causes/syc-20350961
• National Institute of Mental Health. (2023). Depression. https://www.nimh.nih.gov/health/topics/depression
• World Health Organization. (2019). Mental health: Strengthening our response. WHO. https://www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-response
• Lucke, J. F., & Bonifacio, M. J. (2020). Applying a strengths-based model in case management. Journal of Social Work Practice, 34(2), 149–163.
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• Springer, D. W., & Machell, C. M. (2021). Crisis intervention strategies for mental health crises. Journal of Clinical Psychology, 77(4), 723–739.
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