Writing Treatment Notes
Reply separately to two of your peer’s posts (See attached peer’s posts, post#1 and post#2). Also, please see my attached INITIAL POST.

SOAP NOTE based from the following video: https://youtu.be/pF12xCtHWwc

INSTRUCTIONS:

Your responses should be in a well-developed paragraph (300-350 words) to each peer, and they should include evidence-based research to support your statements using proper citations and APA format!!!Note: DO NOT CRITIQUE THEIR POSTS, Please, add new informative content regarding to their topic that is validated via citations.

Please, send me the two documents separately, for example one is the reply to my peers Post #1, and the second one is the reply to my other peer Post #2.
Minimum of 300 words per peer reply.
In your reply posts, answer the following questions:

Do you agree or disagree with the plan?
Compare your peer’s plan to yours. What are the advantages and disadvantages of each?
Background: I live in South Florida, I am currently enrolled in the Psych Mental Health Practitioner Program, I am a Registered Nurse, I work in a Psychiatric Hospital.

Psychiatric SOAP Note

Discussion 1: Writing Treatment Notes

Family Psychiatric Mental Health I

 

 

 

 

 

 

 

 

 

 

 

 

 

Psychiatric SOAP Note

Criteria Clinical Notes
Subjective Patient Name: Cory

Chief complaint: Grades have been getting worse and patient has difficulty listening to teachers.

Patient admits not to like any particular subjects especially math’s. He finds history more appealing but still cannot concentrate well in class because he is somehow distracted by something.

Patient admits to not playing any sports and says that whilst he participated in basketball and baseball in high school he thinks he can’t find time now and with his performance in school, the mother would allow sports.

Admits to forgetting his homework frequently either because he forgot a notebook, the pen, or some needed material

He feels that he is disappointing his mother but admits he can do very little to change that because he feels he has no control over it

Patient admits to having a not-close relationship with his father or his other sibling (sister)

Patient admits to enjoying video games because they are fun and distracts him from the normal life. He likes outdoor activities but engages in them so that he can be a bit active and ‘mum doesn’t think he isn’t doing anything’

Admits to limited sleeping time due to video games but sees no connection to his school performance and concentration issues

(UMass Nursing 690M, 2016)

Include chief complaint, subjective information from the patient, names and relations of others present in the interview, and basic demographic information of the patient. HPI, Past Medical and Psychiatric History, Social History.  
Objective MSE exam findings: Patient can effectively repeat the three words in the order provided.

Patient can remember the three words and repeat them again few minutes later.

Patient can spell the provided word appropriately (UMass Nursing 690M, 2016)

Mental status exam

Orientation: Alert and oriented x 3

Appearance: The patient was appropriately dressed, and appeared his stated age.

Speech and language: The patient’s speech was slightly fast.

Attitude: The patient was cooperative and calm

Mood: Anxious

Concentration: Impaired concentration

Thought processes and associations: Logical and coherent

Suicidal/homicidal ideations: The patient had no homicidal or suicidal ideations.

Memory: Intact

Insight: Altered

Judgement: Poor

This is where the “facts” are located. Include relevant labs, test results, vitals, and Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…” Include MSE, risk assessment here, and psychiatric screening measure results.  
Assessment  

Differential diagnosis:

1. Attention deficit hyperactivity disorder (ADHD), Unspecified Type. ICD-Code F90. 9

2. Anxiety Disorder, Unspecified. ICD-Code F41. 9

3. Obsessive-compulsive disorder, unspecified ICD-Code F42. 9 (Carr et al., 2016)

 

Primary diagnosis:

Attention deficit hyperactivity disorder (ADHD), Unspecified Type. ICD-Code F90. 9 (Carr et al., 2016)

As evidenced by manifestation of more than five symptoms for over five months including but not limited to lacking attention to detail, difficulty in sustaining attention, easily distracted, poor organization/forgetfulness, and restlessness (American Academy of Family Physicians, 2019)

Obstacles to treatment:

Patient has a problem with forgetfulness which could affect medication adherence.

The absence of a close relation for psychological support and to help in self-organization and self-management such as a sibling limits chances for optimal outcomes (Nimmo-Smith et al., 2020)

 

Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment.  
Plan Patient will be prescribed for Adderall XR (amphetamine) 20mg Tab PO QD as starting dosage. The intention to begin with extended release (XR) is informed by the patient’s lacking organization and forgetfulness. The medication will be maintained for four weeks during which a review will be conducted.

Cognitive Behavioral Therapy (CBT): The intention of CBT in ADHD is to train the brain to respond more appropriately to the primary roles of the patient’s life (Nimmo-Smith et al., 2020). In the patient’s case herein, the ADHD is affecting his studies and the role of CBT is to enable him shed off the negative elements influencing his behaviors and lifestyle (Nimmo-Smith et al., 2020). The CBT will be sustained for four weeks with a maximum of two sessions each week. Patient will be seen again in two weeks.

 

 

 

Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options and complimentary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment.  

References

American Academy of Family Physicians. (2019). DSM-5 Diagnostic Criteria for ADHD. AAFP American Academy of Family Physicians.

Carr, K., RHIT, CCS, CDIP, CCDS, & Trainer, A. I. (2016, May 16). Accurate ICD-10-CM coding for ADHD Assists with Research and Data Collection. ICD-10 News and Information – ICD10monitor.

UMass Nursing 690M. (2016). Psychiatric Interview and Mental Status Exam: Georgianna Shea, Case Study #2. YouTube. https://www.youtube.com/watch?v=pF12xCtHWwc

Nimmo-Smith, V., Merwood, A., Hank, D., Brandling, J., Greenwood, R., Skinner, L., … & Rai, D. (2020). Non-pharmacological Interventions for Adult ADHD: A Systematic Review. Psychological Medicine50(4), 529-541.

 

 

CG&AM&BF_10/10/18