Focused Soap 7
Nursebeauty
PtNameassign3.docxPt Name: M.B
Age: 72 Years old F.
Diagnosis: Generalized Anxiety Disorder/ Insomnia/ Bipolar Disorder
Chief Complain: Unable to sleep Pt is a 72 year old female, who presented to the clinic with her stating that she do not sleep well at night, most times she will stay up for 24 hours or more though she tried to cover up with day time naps. She is having problem processing a protein milk intake and she eats twice daily without snacks because she and her daughter do not have enough to eat at home. She has lost some weight recently. Pt was educated to see her social worker as regards to help with meals. She rated her anxiety to be an 8/10 with 10 being the highest. She stated that staying home contributed much to her anxiety level. Pt endorses hallucination due to CBD gummies she takes for pain. She sees patterns on the carpet and wall. She is not willing to give it up since that is the only thing that helps with her pain. She was a drug addict in her 20's and contacted Hepatitis B from dirty needles. She was sexually abused in her childhood days while in the foster home. She had several abortions and was blessed with one child whom she is living with today. Her list of medications include Aripiprazole (ARIPiprazole) 5 MG Oral Tablet Buspirone HCl (busPIRone HCl) 5 MG Oral Tablet Hydroxyzine HCl (hydrOXYzine HCl) 25 MG Oral Tablet Lamotrigine (lamoTRIgine) 25 MG Oral Tablet Mirtazapine 15 MG Oral Tablet. Her medication was called in and she is follow up in a months time.
RESOURCES
· Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
· Section II. The Psychiatric History (Chapters 14–18)
· Section III. Interviewing for Diagnosis: The Psychiatric Review of Symptoms (Chapters 23–24)
· Lorberg, B., Davico, C., Martsenkovskyi, D., & Vitiello, B. (2019). Principles in using psychotropic medication in children and adolescents.Links to an external site. In J. M. Rey & A. Martin (Eds) , IACAPAP e-textbook of child and adolescent mental health (2019 ed., pp. 1–25). International Association for Child and Adolescent Psychiatry and Allied Professions. https://iacapap.org/_Resources/Persistent/45bdffb25befc353c9f61988e82105029504ab85/A.7-Psychopharmacology-2019.1.pdf
· MeditrekLinks to an external site. https://edu.meditrek.com/Default.html Note: Use this link to log into Meditrek to report your clinical hours and patient encounters.
· Document: Focused SOAP Note Template Download Focused SOAP Note Template (Word document)
· Document: Focused SOAP Note Exemplar Download Focused SOAP Note Exemplar (Word document)
FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION, PART 1
Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you examined during the last three weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.
RESOURCES
Be sure to review the Learning Resources before completing this activity. Click the weekly resources link to access the resources.
TO PREPARE
· Review this week's Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
· Select a patient of any age (either a child or an adult) that you examined during the last 3 weeks.
· Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations. Please Note:
· All SOAP notes must be signed, by your Preceptor. Note: Electronic signatures are not accepted.
· When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of the completed assignment signed by your Preceptor.
· You must submit your SOAP note using Turnitin. Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.
· Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record.
· Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
· Ensure that you have the appropriate lighting and equipment to record the
|
|
