Homework 1

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Assignment instructions:

1. Read through the PCP Referral Note (in orange font). You may also download the PCP Referral Note as a separate PDF

2. download 3. . 4. Then, follow the directions for completing the two sections of Directions for

writing a BHS chart note to PCP (in green font). The directions for completing the assignment are located towards the bottom of this page.

5. Review and abide by the assignment instructions regarding APA style, format, and font size - which are all located the bottom of this page.

PCP Referral Note

S: CC: Obesity. History of present illness: 69-year-old African American married male with type 2 diabetes started on Qsymia 2 weeks ago secondary to obesity. He has been thoroughly pleased with the results. He notes his weight is down 18 pounds over the past 2 weeks. He says that after all the diets he has been on this is the first time he feels he has a chance to significantly reduce his weight. He states that he feels great. He denies any palpitations or increased anxiety. He denies any added difficulty sleeping. He notes his appetite is dramatically controlled. He has avoided bread, butter, junk food, sugar and other high glycemic index foods. He has been reading the calorie counts on all of the foods that he consumes. He has reduced the amount of coffee he consumes.

Patient has still not been doing any exercise outside of the limited amount of exercise he gets at helping his wife to care for his four grandchildren. Patient asked about the possibility of reducing some of his medications as he continues to lose weight. He is currently on levothyroxine 100 mcg daily as well as a blood pressure medication. He is tolerating all of these medications well without cough or myalgias.

Current Medications:

Rx: LISINOPRIL 40 MG 1 daily - days, 90, Ref: 3

Rx: LEVOTHYROXINE SODIUM 100mcg 1tab daily - days, 90, Ref: 3

Rx: QSYMIA 3.75mg/23mg 1 tab every other day - days, 14, Ref: 0

https://webcourses.ucf.edu/courses/1379937/files/87210323/download?wrap=1

https://webcourses.ucf.edu/courses/1379937/files/87210323/download?download_frd=1

He does not smoke. Has not been consuming significant amounts of alcohol.

No signs or symptoms of depression, anhedonia or hopelessness.

Review of systems is negative for chest pain, shortness of breath, change in sleep habits, anxiety, palpitations etc. as noted above.

O: On Physical examination: Well-nourished well-developed obese African American male in no apparent distress. Speech, mentation and affect are normal.

Weight: 230 pounds

Height: 5 feet 11 inches

BMI: 32.1

Blood pressure: 130/80

Respirations: 16 and unlabored

Temperature: 98.3

Pulse: initially 88 on arrival dropping to 78 later in the office visit.

Pulse ox: 96% on room air

Lungs: clear

Cardiac: S1 and S2 normal without murmurs.

A/P:

1. Obesity: responding quickly to Qsymia 3.75 mg/23 mg daily. Because he is losing weight too rapidly, will reduce the dose to every other day and see how he does. I recommend that he not exceed weight loss of greater than 5 pounds per week. Ideal weight loss might be closer to 2 pounds per week. He is not currently having any appreciable adverse effects to this medication. A new prescription for 14 tablets is provided which should last him one month. Discussed with him the value of working with our Behavioral Health Specialist in reaching his weight loss goals. He is willing to accept the referral.

2. Hypertension: under improved control with weight loss. Continue current medications but consider possible reduction in antihypertensive medication if blood pressure declines further as he loses more weight.

3. Hypothyroidism: adequately corrected on 100 mcg of levothyroxine daily. No change in her therapy at present time.

Follow up in one month.

Directions for writing a BHS chart note to PCP

Assignment length:

● Section 1: "BHS Chart Note to the PCP" (2 to 3 pages) (10 points) ● Section 2: "Discussion of Your Treatment Rationale" (3 pages) (10 points).

Section 1: BHS chart note to PCP (2 to 3 pages) (10 points)

● Because you are not actually interviewing this patient, you will have to make up and/or embellish the details in this section. You will likely need to add some problems that you will address.

● Keep in mind that even though the patient may state that they are doing “fine” or that they are following through with their plan, patients often have a social desirability bias with doctors and will underreport problems to please the doctor. Many healthcare social workers will often indicate that, once they establish rapport with patients, they uncover social, psychiatric, and behavioral needs that patients have not disclosed to doctors. These scenarios are common occurrences in our field.

● You will not be graded on how you construct the details of the S.O.A. portion. Utilize only one(1) page (at most) for the Subjective, Objective and Assessment sections.

○ You do not have to use a strict S.O.A.P format. There are examples of different note formats in your textbook (refer to pages 97-101, 155-156, 176-177, and 279-280). These examples are all in slightly different formats.

○ You will find that the exact format of your notes will vary from agency setting to agency setting. So, with that in mind, use the format that you feel most comfortable with.

● You will be graded for what you write in the Plan. Please use two (2) to three (3) pages to complete the Plan and be sure to include the following:

○ Special problems the BHS might anticipate with this particular patient;

○ Treatment goals for the behavioral health intervention with this patient;

○ Specific brief counseling methods you would use with the patient; ○ Who you would include in the intervention, and how you would

engage the patient, caregivers and medical team in the intervention plan.

○ Methods of monitoring the patient's progress; ○ Any concerns about co-morbidities and how you would approach

these concerns in your work with the patient; ○ Ethical, cultural or contextual considerations that may affect the

intervention plan. ○ Your follow-up schedule with the patient.

Section 2: Discussion of your treatment rationale (3 pages) (10 points)

● In this section, include your rationale for your treatment goals and treatment plan with this patient.

● The discussion section will be graded based on how you incorporate what you learned in the class about theories of health behavior change and brief counseling approaches. Therefore, refer to and cite course materials in developing the rationale for your treatment goals and treatment plan.

● Use APA citation style for this section. There is no specified number of citations required. Yet, you are expected to make a strong rationale for your approach with your patient, which will be based on course readings and learning amassed to-date.

Assignment Format:

● This assignment should NOT include an abstract, table of contents, or appendix.

● The assignment should be double spaced and include 1" margins throughout.

Font Type and Size:

○ A variety of font choices are permitted in APA Style. Use the same font throughout the text of the paper. Options include:

■ Sans serif font: 11-point Calibri, 11-point Arial, 10-point Lucida San Unicode

■ Serif font: 12-point Times New Roman, 11-point Georgia, normal (10-point) Computer Modern

○ For more information: refer to page 44 of the of APA Publication Manual, Seventh Edition, and this APA Style Font resource.

○ Ensure the font type and font size of your page numbers are consistent with the rest of your assignment.

Rubric S.O.A.P Note Rubric

Criteria Ratin gs

Pts