FOCUSED SOAP NOTE FOR SCHIZOPHRENIA SPECTRUM
Nursing
FOCUSED SOAP NOTE FOR SCHIZOPHRENIA SPECTRUM, OTHER PSYCHOTIC, AND MEDICATION-INDUCED MOVEMENT DISORDERSFor this assignment, you will complete a focused SOAP note for a patient in a case study who has either a schizophrenia spectrum, other psychotic, or medication-induced movement disorder.
THE ASSIGNMENT
Develop a focused SOAP note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:
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 the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, and list them 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 you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Plan: What is your plan for psychotherapy? What is 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. Also, incorporate 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 again? Discuss what your next intervention would be if you were able to follow up with this patient. Also, include in your 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 your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).
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Step 1: Subjective
This section should include information the patient has given you about their symptoms, history, and impact on life.
- Identify the patient’s chief complaint and document the symptoms they are experiencing.
- Describe the duration and severity of their symptoms.
- Discuss how these symptoms are impacting their daily life and functionality.
Step 2: Objective
This section is where you record your observations and results from the psychiatric assessment.
- Document your observations during the psychiatric assessment. This may include the patient’s behavior, appearance, speech pattern, mood, and affect.
Step 3: Assessment
This section is where you document the patient’s mental status examination results and provide your differential diagnoses.
- Write down the results from the patient’s mental status examination.
- List a minimum of three possible diagnoses, ordered from highest to lowest priority. For each possible diagnosis, provide supporting evidence, compare it with the DSM-5-TR diagnostic criteria, and explain why it could or could not be the primary diagnosis.
- Discuss the critical-thinking process that led you to your primary diagnosis selection.
Step 4: Plan
This is where you outline the treatment and management plan for the patient.
- Describe your plan for psychotherapy and any pharmacologic and nonpharmacologic treatments you recommend.
- Discuss any alternative therapies you think would be appropriate.
- Outline the follow-up parameters and provide a rationale for your treatment plan.
- Incorporate one health promotion activity and one patient education strategy.
Step 5: Reflection notes
This section is for self-evaluation and contemplation about the patient’s treatment and your professional growth.
- Reflect on your session with the patient and note any changes you would make if you had the opportunity to conduct the session again.
- Discuss your next steps if you were able to follow up with the patient.
- Incorporate a discussion related to legal/ethical considerations beyond confidentiality and consent for treatment.
- Discuss health promotion, disease prevention, and patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
Step 6: References
Your assignment should be supported by evidence-based, peer-reviewed journal articles or guidelines.
- Provide at least three recent (within the last 5 years) peer-reviewed articles or evidence-based guidelines that relate to this case.
Step 7: Review and Edit
Before submitting your assignment, take the time to thoroughly review and edit your work.
- Make sure your language is clear, your grammar is correct, and your work is free from spelling errors.
- Ensure that you have fully addressed all aspects of the assignment and that your work flows logically.
This is a general guideline to follow. The specifics will depend on the case study you have been given. Good luck with your assignment!
