Posted: September 19th, 2022

Develop a Focused SOAP Note, Case Study: Dev Cordoba

To Put together

 Assessment this week’s Studying Assets. Think about the insights they supply about assessing and diagnosing anxiousness, obsessive compulsive, and trauma-related problems.
 Assessment the Focused SOAP Word template, which you’ll use to finish this Task. There’s additionally a Focused SOAP Word Exemplar offered as a information for Task expectations.
 Assessment the video, Case Research: Dev Cordoba. You’ll use this case as the idea of this Task. On this video, a Walden school member is assessing a mock affected person. The affected person shall be represented onscreen as an avatar.
 Think about what historical past could be essential to gather from this affected person.
 Think about what interview questions you would want to ask this affected person.

The Task

Develop a Focused SOAP Word, together with your differential prognosis and critical-thinking course of to formulate a main prognosis. Incorporate the next into your responses within the template:
 Subjective: What particulars did the affected person present relating to their chief grievance and symptomology to derive your differential prognosis? What’s the length and severity of their signs? How are their signs impacting their functioning in life?
 Goal: What observations did you make throughout the psychiatric Assessment?
 Assessment: Focus on the affected person’s psychological standing examination outcomes. What had been your differential diagnoses? Present a minimal of three attainable diagnoses with supporting proof, listed so as from highest precedence to lowest precedence. Examine the DSM-5-TR diagnostic standards for every differential prognosis and clarify what DSM-5-TR standards guidelines out the differential prognosis to seek out an correct prognosis. Clarify the critical-thinking course of that led you to the first prognosis you chose. Embrace pertinent positives and pertinent negatives for the particular affected person case.
 Plan: What’s your plan for psychotherapy? What’s your plan for remedy and administration, together with various therapies? Embrace pharmacologic and nonpharmacologic therapies, various therapies, and follow-up parameters, in addition to a rationale for this remedy and administration plan. Additionally incorporate one well being promotion exercise and one affected person schooling technique.
 Reflection notes: What would you do in a different way with this affected person when you might conduct the session once more? Focus on what your subsequent intervention could be when you might comply with up with this affected person. Additionally embrace in your reflection a dialogue associated to authorized/moral issues (reveal essential considering past confidentiality and consent for remedy!), well being promotion, and illness prevention, making an allowance for affected person components (resembling age, ethnic group, and many others.), PMH, and different danger components (e.g., socioeconomic, cultural background, and many others.).
 Present no less than three evidence-based, peer-reviewed journal articles or evidenced-based pointers that relate to this case to help your diagnostics and differential diagnoses. Make sure they’re present (not more than 5 years outdated).

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