Select a child/adolescent or adult 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. Include the complete SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor. You must submit your SOAP Note using SafeAssign.
3). Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice what you will say beforehand and ensure that you have the appropriate lighting and equipment to record the presentation.
4). Your presentation should include objectives for your audience, at least 3 possible discussion questions/prompts for your classmates to respond to, and at least 5 scholarly resources to support your diagnostic reasoning and treatment plan.
5). Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
6). Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
7). Pose three questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.
8). 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?
9). Objective: What observations did you make during the psychiatric assessment?
10). 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.
11). 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).
12). 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, discuchoss what your next intervention would be.
