WEEK 7 - FOCUSED SOAP NOTE -Personality and Paraphilic Disorders

WEEK 7 – FOCUSED SOAP NOTE

REQUIRED LEARNING RESOURCES

Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.

· Chapters 31, “Assessing Personality Disorders”

· Chapter 32, “How to Educate Your Patient”

https://health.gov/healthypeople/priority-areas/social-determinants-health

https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bpd.pdf

https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bpd-watch.pdf

https://www.youtube.com/watch?v=YOV61lKxqxY

https://www.youtube.com/watch?v=0TtryBLokZc

Rubric Detail

 

Objectives for the Presentation--

Excellent 5 (5%) - 5 (5%)

Good 4 (4%) - 4 (4%)

Fair 3.5 (3.5%) - 3.5 (3.5%)

Poor 0 (0%) - 3 (3%)

Discuss subjective data:

• Chief complaint

• History of present illness (HPI)

• Medications

• Psychotherapy or previous psychiatric diagnosis

• Pertinent histories and/or ROS

--

Excellent 5 (5%) - 5 (5%)

Good 4 (4%) - 4 (4%)

Fair 3.5 (3.5%) - 3.5 (3.5%)

Poor 0 (0%) - 3 (3%)

Discuss objective data:

• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history

• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses

--

Excellent 9 (9%) - 10 (10%)

Good 8 (8%) - 8 (8%)

Fair 7 (7%) - 7 (7%)

Poor 0 (0%) - 6 (6%)

Discuss results of assessment:

• Results of the mental status examination

• Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.

--

Excellent 18 (18%) - 20 (20%)

Good 16 (16%) - 17 (17%)

Fair 14 (14%) - 15 (15%)

Poor 0 (0%) - 13 (13%)

Discuss treatment plan:

• A treatment plan for the patient that addresses psychotherapy; one health promotion activity and one patient education strategy; plan for treatment and management, including alternative therapies; pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters; and a rationale for the approaches selected. Discusses an identified social determinate of health impacting this patient’s mental health status and provide your recommendation for a referral to assist this patient in meeting this identified need

--

Excellent 18 (18%) - 20 (20%)

Good 16 (16%) - 17 (17%)

Fair 14 (14%) - 15 (15%)

Poor 0 (0%) - 13 (13%)

Reflect on this case. Discuss what you learned and what you might do differently.

Pose 3 questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.

--

Excellent 5 (5%) - 5 (5%)

Good 4 (4%) - 4 (4%)

Fair 3.5 (3.5%) - 3.5 (3.5%)

Poor 0 (0%) - 3 (3%)

Focused SOAP Note--

Excellent 9 (9%) - 10 (10%)

Good 8 (8%) - 8 (8%)

Fair 7 (7%) - 7 (7%)

Poor 0 (0%) - 6 (6%)

Presentation Style--

Excellent 5 (5%) - 5 (5%)

Good 4 (4%) - 4 (4%)

Fair 3.5 (3.5%) - 3.5 (3.5%)

Poor 0 (0%) - 3 (3%)

Discussion Facilitation--

Excellent 9 (9%) - 10 (10%)

Good 8 (8%) - 8 (8%)

Fair 7 (7%) - 7 (7%)

Poor 0 (0%) - 6 (6%)

Total Points: 100

THE ASSIGNMENT: FOCUSED SOAP NOTE

Personality and Paraphilic Disorders

To prepare: 

· Select a child/adolescent patient  from your clinical experience that presents with a significant concern. Create a focused SOAP note for this patient using the template in the Resources. 

· Your presentation should include objectives for your audience, at least three possible discussion questions/prompts for your classmates to respond to, and at least five scholarly resources from 2018-2022 to support your diagnostic reasoning and treatment plan.

· Be succinct in your presentation, and specifically address the following for the patient, using your SOAP note as a guide.

· 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 their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with  DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms.

· Plan: What was your plan for psychotherapy (include one health promotion activity and patient education)? What was 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.  Discuss an identified social determinate of health impacting this patient’s mental health status and provide your recommendation for a referral to assist this patient in meeting this identified need (students will need to conduct research on this topic both in the literature and for community resources).

· Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow-up, discuss what your next intervention would be.

· Case Formulation