Assignment: Focused SOAP Note for Anxiety, PTSD, and OCD In assessing patients w

Assignment: Focused SOAP Note for Anxiety, PTSD, and OCD
In assessing patients with anxiety, obsessive-compulsive,
and trauma and stressor-related disorders, you will continue the practice of
looking to understand chief symptomology in order to develop a diagnosis. With
a differential diagnosis in mind, you can then move to a treatment and
follow-up plan that may involve both psychopharmacologic and psychotherapeutic
approaches.
In this Assignment, you use a case study to develop a
focused SOAP note based on evidence-based approaches.
To Prepare
Review this week’s Learning Resources. Consider the insights
they provide about assessing and diagnosing anxiety, obsessive compulsive, and
trauma-related disorders.
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: Dev Cordoba. 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.
The Assignment
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, listed in order from highest
priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each
differential diagnosis and explain what DSM-5-TRcriteria 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 could 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).