SOAP 9
Nursebeauty
PtNameassign3.docx· Pt Name: J.N
· Age: 12 Years old F.
· Diagnosis: ADHD Chief / Major Anxiety Depression/ Insomnia
· Complain: Doing well
· Summary of visit: Pt is a 12-year-old female, who presented to the clinic with her mum complaining that she can barely focus on any task. You must do a lot of encouragement to get her to complete a task. Sometimes she refuses to take her medication, insisting that she is okay. She is now seeing a therapist once a week and that seems to help so far. She does not get enough sleep for the night. Pt denied having any thought of SI/HI. Pt said she experiences some form of anxiety. She denied depression. She was educated about the importance of taking her medications because it will help with her symptoms and improve her overall health. She promised to do better. Her medication includes Guanfacine HCl (ADHD) (guanFACINE HCl ER) 2 MG Oral Tablet Extended Release 24 Hour. Melatonin 5 mg nightly. She is to follow up in a months’ time with her medication refill called in.
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· Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
· Chapter 32, “How to Educate Your Patient”
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· 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
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