FOCUSED SOAP NOTE FOR SCHIZOPHRENIA SPECTRUM, OTHER PSYCHOTIC, AND MEDICATION-INDUCED MOVEMENT DISORDERS
Psychotic disorders change one’s sense of reality and cause abnormal thinking and perception. Patients presenting with psychotic disorders may suffer from delusions or hallucinations or may display negative symptoms such as lack of emotion or withdraw from social situations or relationships. Symptoms of medication-induced movement disorders can be mild or lethal and can include, for example, tremors, dystonic reactions, or serotonin syndrome.
For this Assignment, you will complete a focused SOAP note for a patient in a case study who has either a schizophrenia spectrum, other psychotic, or medication-induced movement disorder.
Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
Review the video, Case Study: Sherman Tremaine. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
Consider what history would be necessary to collect from this patient.
Consider what interview questions you would need to ask this patient.
Develop a focused SOAP note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:
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 the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, and list them in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Plan: What is your plan for psychotherapy? What is 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. Also incorporate one health promotion activity and one patient education strategy.
Reflection notes: What would you do differently with this patient if you could conduct the session again? Discuss what your next intervention would be if you were able to follow up with this patient.?Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion, and disease prevention, taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).
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Assignment: Focused SOAP Note for Schizophrenia Spectrum, Other Psychotic, and Medication-Induced Movement Disorders
Psychotic disorders, including schizophrenia spectrum and other psychotic disorders, can significantly impact an individual’s sense of reality, causing abnormal thinking and perception. These disorders may manifest as delusions, hallucinations, or negative symptoms such as emotional withdrawal or a decline in social functioning. Additionally, medication-induced movement disorders can range from mild to severe and may be characterized by symptoms like tremors, dystonic reactions, or serotonin syndrome.
For this assignment, you are required to complete a focused SOAP note for a patient with either schizophrenia spectrum, other psychotic disorder, or medication-induced movement disorder, based on a provided case study. The SOAP note should include a differential diagnosis, as well as a comprehensive assessment of the patient’s symptoms and critical-thinking process leading to the primary diagnosis. Furthermore, you need to develop a treatment plan, including psychotherapy, pharmacologic and nonpharmacologic interventions, and health promotion strategies, while considering legal/ethical considerations and patient factors.
Answer to the Content:
To effectively complete this assignment, you should follow the guidelines provided in the Focused SOAP Note template and refer to the Focused SOAP Note Exemplar for guidance. Additionally, watch the video “Case Study: Sherman Tremaine” where a Walden faculty member assesses a mock patient. Consider the patient’s history and formulate appropriate interview questions to elicit the necessary information.
In your SOAP note, address the following sections:
– Gather details regarding the patient’s chief complaint and symptomology.
– Assess the duration and severity of symptoms.
– Evaluate how symptoms are impacting the patient’s functioning in life.
– Document your observations during the psychiatric assessment.
– Discuss the patient’s mental status examination results.
– Develop a list of differential diagnoses with supporting evidence.
– Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and rule out diagnoses that do not meet the criteria.
– Explain the critical-thinking process that led to the primary diagnosis.
– Include pertinent positives and negatives specific to the patient case.
– Formulate a plan for psychotherapy.
– Outline the treatment and management plan, including pharmacologic and nonpharmacologic interventions.
– Provide alternative therapies and follow-up parameters.
– Justify the chosen treatment and management plan.
– Include one health promotion activity and one patient education strategy.
5. Reflection notes:
– Reflect on the session with the patient and identify any potential areas for improvement.
– Discuss potential next interventions if able to follow-up with the patient.
– Incorporate legal/ethical considerations, health promotion, and disease prevention, taking into account patient factors and risk factors.
Remember to support your diagnostic and differential diagnoses with evidence-based knowledge by referencing at least three current (no more than 5 years old), peer-reviewed journal articles or evidence-based guidelines relevant to this case.
In conclusion, this assignment requires you to complete a focused SOAP note for a patient with schizophrenia spectrum, other psychotic disorder, or medication-induced movement disorder. You need to demonstrate your differential diagnosis, critical-thinking process leading to the primary diagnosis, and formulate a comprehensive treatment plan. Additionally, reflect on the session and consider legal/ethical considerations, health promotion, and disease prevention strategies.