Need A Total Of 25 Mini Soap Notes For Patients Aged 1

Need A Total Of 25 Mini Soap Notes Patients Should Be Ages 18 And You

Need a total of 25 mini soap notes. Patients should be ages 18 and younger. Example provided: 17 y/o African American, female “Follow up on my mood”S: Patient is being seen for a follow up visit. Patient has a history of depression, bipolar, gender identity crisis and cannabis use. Patient recently changed her name stating her birth name wasn't “identifiable”.Patient has complaints of feeling mentally drained and overworked. She states she's tired and is considering going to an inpatient mental health facility for a few days. Patient who lives at home with her parents has decided that it would be best if she went to live with her grandmother. She states her parents does not understand her identity. She has resorted to excessive alcohol and marijuana use to “ease the pain”.Patient has exhibited symptoms of impulsive behaviors by going on shopping sprees, only using her credit cards. Patient is currently taking Abilify 20mg PO daily, Sertraline 50mg PO daily and Concerta 27mg PO daily. NKDA.O: Temp 97.9, BP 122/80, HR 70, O2 sats 99%.A: Bipolar disorder- Bipolar I Disorder - F31.13 Substance Use Disorder (Alcohol and Marijuana) - F10.20, F12.10P: Increase Abilify to 30mg PO daily. Continue all other psychiatric medications as prescribed and monitored for changes in behavior and/or adverse reactions. Education provided to patient. Reviewed medication side effects and adherence importance. Keep track of physical symptoms of mood and depression and triggers associated. Discussed worsening signs and symptoms and when to contact office or report to ED. Patient advised to continue with outpatient counseling. Referred to substance abuse treatment program. Follow up in four weeks or sooner if symptoms worsen.

Paper For Above instruction

Creating 25 mini SOAP notes involving adolescent patients requires attention to detail, confidentiality, and a structured approach to documenting clinical encounters. SOAP notes (Subjective, Objective, Assessment, Plan) serve as essential documentation tools for healthcare providers to monitor patient progress, guide treatment plans, and ensure continuity of care. For adolescent patients aged 18 and younger, these notes must reflect pertinent clinical information, developmental considerations, and tailored interventions suitable for this age group.

In crafting these mini SOAP notes, each entry should include a comprehensive subjective account, noting patient-reported symptoms and concerns, and an objective section with vital signs, physical findings, and mental status assessments. The assessment should synthesize clinical impressions, diagnoses, and relevant comorbidities. The plan should articulate specific interventions, medication adjustments, counseling efforts, referrals, and follow-up instructions, all tailored to the adolescent's developmental stage and psychosocial context.

For example, consider a 17-year-old African American female presenting for follow-up on mood symptoms. She reports feeling mentally drained, overwhelmed, and contemplating inpatient care due to her bipolar disorder and substance use. Her history includes depression, bipolar disorder, gender identity concerns, and cannabis use. The clinician should evaluate her current mental state, medication adherence, and social support systems. Interventions might include medication adjustments, psychoeducation, safety planning, and referrals to mental health and substance use treatment programs.

Each note must capture essential clinical data, such as vital signs, mental status, and risk assessments, while respecting confidentiality, especially when documenting sensitive information like gender identity or substance use. Additionally, providing education about medication adherence, warning signs of worsening mental health, and when to seek emergency care is critical in adolescent psychiatry.

Developing these 25 notes not only enhances clinical documentation skills but also contributes to better patient care outcomes by ensuring detailed, accurate, and timely information recording. These notes should cover a variety of adolescent presentations, including mood disorders, anxiety, behavioral issues, substance use, and developmental concerns, reflecting a broad spectrum of mental health challenges faced by this age group.

References

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
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  • Kessler, R. C., et al. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 617-627.
  • Lewinsohn, P. M., et al. (1998). The epidemiology of adolescent depression: An update. Journal of the American Academy of Child & Adolescent Psychiatry, 37(3), 278-285.
  • Wilens, T. E. (2008). Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 47(4), 489-511.
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  • American Academy of Pediatrics. (2014). Bright Futures: Guidelines for health supervision of infants, children, and adolescents.
  • Blow, A. J., & Kates, W. R. (2010). Substance use in adolescents. Child and Adolescent Psychiatric Clinics, 19(2), 275-290.
  • Costello, E. J., et al. (2003). Developmental epidemiology of anxiety disorders. Journal of Child Psychology and Psychiatry, 44(7), 180-193.

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