ASSESSMENT
Create a SOAP Note using the attached Template, fill the information on the provided SOAP Note attachment.
Step 2: Each student will create a focused SOAP note PowerPoint presentation. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive psychiatric SOAP note is to be written using the attached template below.
| S = | Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS) |
| O = | Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam, (Focused), and Mental Status Exam |
| A = | Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes |
| P = | Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up |
Complete this assessment using your critical thinking skills. You are expected to synthesis your clinical assessment, formulate a psychiatric diagnosis, and develop a treatment plan independently.
Complete this assessment using your critical thinking skills. Synthesis your clinical assessment, formulate a psychiatric diagnosis, and develop a treatment plan independently.
