Our Services

Get 15% Discount on your First Order

[rank_math_breadcrumb]

SOAP NOTE/Case study

 SOAP note based on youtube video.

Template provided.

3 References needed

Review the video: 
Psychiatric Interview and Mental Status Exam

Complete a SOAP not based on youtube video. Template provided below.

SOAP note should include a comprehensive treatment plan which incorporates both psychosocial interventions as well as a medication plan, if indicated, with collateral information.

3 References (no more than 5 years old)

TEMPLATE:

Patient Name: XXX

MRN: XXX

Date of Service: 01-27-2020

Start Time: 10:00
End Time: 10:54

Billing Code(s): 90213, 90836

(be sure you include strictly psychotherapy codes or both E&M and add on psychotherapy codes if prescribing provider visit)

Accompanied by: Brother

CC: follow-up appt. for counseling after discharge from inpatient psychiatric unit 2 days ago

HPI: 1 week from inpatient care to current partial inpatient care daily individual psychotherapy session and extended daily group sessions

S- Patient states that he generally has been doing well with depressive and anxiety symptoms improved but he still feels down at times. He states he is sleeping better, achieving 7-8 hours of restful sleep each night. He states he feels the medication is helping somewhat and without any noticeable side-effects.

Crisis Issues: He states he has no suicide plan and has not thought about suicide since the recent attempt. He states has no access to prescription medications, other than the fluoxetine. He believes the classes he participated in while inpatient have helped him with coping mechanisms.

Reviewed Allergies: NKA

Current Medications: Fluoxetine 10mg daily

ROS: no complaints

O-

Vitals: T 98.4, P 82, R 16, BP 122/78

PE: (not always required and performed, especially in psychotherapy only visits)

Heart- RRR, no murmurs, no gallops

Lungs- CTA bilaterally

Skin- no lesions or rashes

Labs: CBC, lytes, and TSH all within normal limits

Results of any Psychiatric Clinical Tests: BAI=34

MSE:

Gary Davis, a 36-year-old white male, was disheveled and unkempt on presentation to the outpatient office. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age. During the interview, he was attentive and calm. He was impatient, but polite in his interactions with this examiner. Mr. Davis reported that today was the best day of his life, because he had decided he was going to be better and start his own company. His affect was labile, but appropriate to the content of his speech (i.e., he became tearful when reporting he had “bogeyed number 15” in gold yesterday). His speech was loud, pressured at times then he would quickly gain composure to a more neutral tone. He exhibited loosening of associations and flight of ideas; he intermittently and unpredictably shifted the topic of conversation from golf, to the mating habits of geese, to the likelihood of extraterrestrial life. Mr. Davis described grandiose delusions regarding his sexual and athletic performance. He reported no auditory hallucinations. He was oriented to time and place. He denied suicidal and homicidal ideation. He refused to participate in intellectual- or memory-related portions of the examination. Reliability, judgment, and insight were impaired.

A – with (ICD-10 code)

Differential Diagnoses:

1. choose 3 differential diagnoses

2.

3.

Definitive Diagnosis:

Major Depressive Disorder, recurrent, without psychotic features F33.4

Generalized Anxiety Disorder F41.1

P- Continue Fluoxetine increasing dose to 20mg.

Continue outpatient counseling: partial inpatient program continued with individual and group sessions

Non-pharmacological Tx: Psychotherapy Modality used: CBT

Pharmacological Tx: (be specific and give detailed Rx information)

Education: discussed smoking cessation

Reviewed medication side effects and adherence importance

Follow-up: in one week or earlier if any depressive symptoms worsen.

Referrals: none at this time

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

resp 1

attached Your responses are to be polite and reflect best practice as displayed in the literature. Please don’t provide unsubstantiated opinion. You should make at least 2 substantial posts (including responses to others.  A substantial responses is  not something like: Good post Great idea Thanks for a good post   (

resp 2

attached Your responses are to be polite and reflect best practice as displayed in the literature. Please don’t provide unsubstantiated opinion. You should make at least 2 substantial posts (including responses to others.  A substantial responses is  not something like: Good post Great idea Thanks for a good post   (

Psychology ABA 503- Assignment 3

Rubric for ABA503 Assignment 3 Grading item Completely accurate in content and clearly articulated Partially inaccurate in content OR somewhat unclear in articulation Partially inaccurate in content AND unclear in articulation Item is missing or completely inaccurate in content FA Condition 1 (MO and consequences) 10 3 1 0 FA

Integration Seminar

see attachment  Interview Presence Instructions: While our course is focused on the psychological interview, there are similarities with job interviews. Let’s take the perspective of the one being interviewed. Think about the different interviews you have participated in as the interviewee and answer the following: 1. Were there any that

DIS 1

Attached DO NOT USE CHAT GPT OR ANY OTHER THAT PLATAFORM THAT CAN COMPROMISE YOUR GRADE. Discussion 1  – This assignment will use the Assignment Rubric. Your original posts and responses are to be reflective of the current literature, clearly state your position, and be brief but thorough. Your responses should

week 7 final

help Immersion Project: Exploring Deaf Culture Through Observation and Dialogue Introduction Deaf culture is a vibrant and resilient community defined not by impairment but by shared language, values, and lived experiences. For my Immersion Project, I engaged in two complementary activities: attending a Deaf community social event and conducting a

MSW 525 MODULE 8

Trauma Treatment Plan READINGS: Saxe, G., Ellis, B.H. & Brown, A. (2016).  Trauma systems therapy for children and teens. Guilford Press · Chapter 10: Treatment Planning: How to Use the Information You’ve Gathered to Plan What You Will Do · Chapter 12: Safety-Focused Treatment: Establishing and Maintaining Safe Environments for

mental health disorders

  Step One: Locate a minimum of five scholarly (peer-reviewed) journal articles that will help you learn about the disorder you selected (your textbook counts as a scholarly source as well). When doing your research, you should look for articles that: describe/explain the symptoms associated with the disorder that explain biological causes

MSW 531 MODULE 8

McInnis-Dittrich, K. (2020). Social work with older adults: A biopsychosocial approach to assessment and intervention (5th ed.). Pearson. · Chapter 1: The Context of Social Work Practice with Older Adults, pp 8-18 · Chapter 12: Working with Older Adults’ Support Systems in Caregiving Ferraro, K., & Wilmoth, J. (Eds.) (2013). Gerontology: Perspectives and

Psychology Assignment

Please work through this . No AI used and please follow the instructions     Post a 200- to 250-word response, in which you: Select one specific substance from Module 11 ( psych/chapter/module-11-substance-related-and-addictive-disorders/) that is abused and describe a possible cause of it. Explain your position on whether

FP Week 4 Assignment

Q1. What are the methods used for biological sex identification?  (5 points) Q2. What is photo-superimposition? (5 points) 

FP Week 4 Discussion 2

Injuries (Wounds) What are the differences between lacerated and incised wounds? What are the circumstances under which these types of injuries may occur?

Prof Double R

 I NEED TWO PARAGRAPHS BY THURSDAY Given the current pressure to reform US health care and contain its costs, how might health psychologists and/or research in the field of health psychology be helpful during the development of future policy? Also, how could/will you use the information you learned in this

Integration Seminar

see attachment  nterview and Communication Styles Instructions: 1. Use the virtual library to review different interview styles. 2. Compile a list of interview and communication styles and do additional research about them. 3. Research your chosen interview and communication styles and prepare a Venn Diagram comparing them.  4. Include an

case study

 psychological based intervention to help someone to quit smoking · Case Study (2500 words -40%) · Assignment Title:  proposed topics: · Design a psychological based intervention to help someone to quit smoking. In your answer include a short section explaining how you would evaluate your proposed programme/intervention · Weighting: 40%  · Limits: 2500

PE Week 9 Assignment 3

To prepare: Reflect on this week’s experiences with your team. Assignment Complete your journal entry for this week in your Personal Journal, reflecting on your experiences with the team process for this week. How is it going? What are you learning about yourself? What are you learning about the team

PE Week 9 Assignment 2

 Whom will you involve in drawing, interpreting, and justifying conclusions?   What are your plans to involve them in this process?

WEEK 8

Immersion Project Paper For this Assignment, you will submit your Immersion Project Paper, one of two culminating parts of your final project for this course (along with your narrated PowerPoint presentation, which is due in Week 9). This paper is a culmination of what you have experienced and explored throughout