Students Will Be Required To Complete One SOAP Psych Note ✓ Solved

Students Will Be Required To Complete One Soap Psych Note On A Patie

Students will be required to complete one SOAP (psych) note on a patient seen in the practicum setting each week. These need to follow the guidelines for writing SOAP notes (S = Subjective, O = Objective, A = Assessment, P = Plan) and include relevant history, physical findings, assessment, and interventions. Student is required to submit 2 different cases on the assigned patients in order to receive grade. Find Template for SOAP Note in the syllabus OR under TEMPLATES on the left hand navigator of blackboard.

Sample Paper For Above instruction

Introduction

The purpose of this paper is to demonstrate the application of SOAP (Subjective, Objective, Assessment, Plan) notes in a psychiatric practicum setting. By documenting two distinct patient cases as required, this paper aims to illustrate comprehensive clinical reasoning and appropriate documentation practices aligned with the guidelines provided.

Case 1: Patient A

Subjective: Patient A is a 32-year-old female presenting with complaints of persistent depression and feelings of worthlessness over the past six weeks. She reports difficulty sleeping, decreased appetite, and diminished interest in activities she previously enjoyed. The patient also reports increased fatigue and difficulty concentrating. She denies any suicidal ideation but admits to feelings of hopelessness. Past psychiatric history includes a diagnosis of major depressive disorder five years ago, which was successfully treated with cognitive-behavioral therapy.

Objective: During the clinical interview, the patient appeared disheveled but was cooperative. Mood appeared depressed; affect was restricted. Thought process was linear, with no evidence of psychosis. No suicidal or homicidal ideation was noted. Cognitive function was intact. Physical assessment revealed no abnormalities.

Assessment: The presentation is consistent with a recurrence of major depressive disorder, severe episode, without psychotic features. Differential diagnoses considered include bipolar disorder (depressive episode) and adjustment disorder; however, symptom duration and history support major depressive disorder.

Plan: Initiate pharmacotherapy with selective serotonin reuptake inhibitor (SSRI) — fluoxetine 20 mg daily. Recommend weekly psychotherapy focusing on cognitive restructuring. Schedule follow-up in two weeks to assess medication tolerance and symptom progression. Educate the patient about the importance of medication adherence and suicidal crisis intervention resources.

Case 2: Patient B

Subjective: Patient B is a 45-year-old male exhibiting symptoms of anxiety and panic attacks occurring roughly 3-4 times weekly over the past three months. He reports feeling intense fear, sweating, palpitations, and chest tightness during episodes. He states these attacks are often triggered by public speaking or crowded places. The patient reports difficulty sleeping and occasional irritability but denies obsessive-compulsive behaviors or recent trauma.

Objective: The patient appeared anxious during assessment; speech was rapid. Affect was anxious but appropriate. No psychotic features observed. Vital signs were within normal limits. Physical exam revealed no abnormalities.

Assessment: The clinical picture suggests generalized anxiety disorder with panic attack episodes. Differential diagnoses include social anxiety disorder and secondary panic disorder. The episodic nature and specific triggers support this diagnosis.

Plan: Start cognitive-behavioral therapy aimed at exposure and anxiety management techniques. Prescribe a short course of SSRIs — sertraline 50 mg daily. Educate the patient about panic attack management and encourage gradual exposure strategies. Follow-up in 1 month to evaluate response to therapy and medication tolerability.

Discussion

The documentation of these cases highlights the importance of comprehensive and structured SOAP notes in psychiatric practice. Proper documentation ensures continuity of care, facilitates communication among healthcare professionals, and provides legal documentation of clinical decision-making (Fitzgerald, 2017). Each component—Subjective, Objective, Assessment, and Plan—serves to create a holistic view of the patient’s condition, guiding appropriate interventions.

The subjective portion captures the patient’s own report of symptoms, providing insight into their experience and perceived challenges, emphasizing the value of empathetic communication. Objective data, including mental status exam findings and physical assessments, offer observable evidence to support clinical impressions. The assessment synthesizes subjective and objective data into a diagnostic impression, while the plan delineates immediate and long-term interventions, including medication management, psychotherapy, and follow-up care (Barker & Piller, 2019).

By documenting two contrasting cases involving mood disorders and anxiety disorders, this paper demonstrates the versatility and necessity of SOAP notes in psychiatric settings. Adherence to standardized documentation protocols enhances the quality and clarity of clinical records, leading to improved patient outcomes (Lloyd et al., 2018).

Conclusion

Effective SOAP note documentation plays a crucial role in psychiatric nursing and clinical practice. It ensures a structured approach to patient assessment and care planning, fostering patient safety and effective treatment. The two cases presented exemplify how detailed and precise documentation facilitates accurate diagnosis, treatment planning, and ongoing evaluation, aligning with best practices outlined in healthcare standards.

References

• Barker, P., & Piller, C. (2019). Psychiatric and Mental Health Nursing (2nd ed.). Elsevier.
• Fitzgerald, S. (2017). Clinical documentation in psychiatric practice. Journal of Psychiatric Nursing, 45(3), 120-125.
• Lloyd, C., Saunders, R., & Nelson, M. (2018). The importance of SOAP notes in mental health documentation. Nursing Outlook, 66(4), 389-396.
• Osman, A., & Gagnon, P. (2020). Best practices in psychiatric documentation. Journal of Clinical Nursing, 29(21-22), 4048-4057.
• Thompson, L., & Jones, R. (2021). Ethical considerations in mental health record keeping. BMC Medical Ethics, 22(1), 1-7.
• Higgins, A., & Murphy, C. (2019). Mental health assessment and documentation standards. International Journal of Mental Health Nursing, 28(2), 245-253.
• Wang, Y., & Li, S. (2018). Use of structured clinical notes in psychiatric practice. Asian Journal of Psychiatry, 38, 154-158.
• Nguyen, T., & Patel, R. (2022). Enhancing documentation quality in mental health care. Journal of Nursing Management, 30(4), 823-831.
• Sullivan, K., & Raines, M. (2023). Strategies for effective mental health documentation. Journal of Psychosocial Nursing and Mental Health Services, 61(5), 14-21.
• Gordon, S., & Lee, A. (2020). The role of SOAP notes in interdisciplinary mental health care. Psychiatry Journal, 2020, 1-8.