Unit 4 Assignment SOAP NOTE Case Study 2

Posted: August 7th, 2024

Unit 4 Assignment SOAP NOTE/Case Study 2

SOAP Note

Patient Name: G.D. MRN: XXX Date of Service: 01-27-2020 Start Time: 10:00 AM End Time: 10:54 AM Billing Code(s): 90213, 90836 Accompanied by: Brother CC: Follow-up appointment for counseling after discharge from inpatient psychiatric unit 2 days ago

Subjective (S): Mr. Davis reports generally improved depressive and anxiety symptoms but still feels down at times. He states he is sleeping better, achieving 7-8 hours of restful sleep nightly. He finds the medication somewhat helpful without noticeable side effects. Mr. Davis believes the coping mechanisms learned during inpatient care have been beneficial. He denies current suicidal ideation or plans and reports no access to prescription medications besides fluoxetine.

Objective (O): Vitals: T 98.4, P 82, R 16, BP 122/78 PE: Not performed during this psychotherapy session Labs: CBC, lytes, and TSH all within normal limits Psychiatric Clinical Tests: BAI = 34

Mental Status Examination: Mr. Davis presented disheveled and unkempt, wearing dirty clothes. He appeared younger than his stated age. During the interview, he was attentive and calm but impatient. He reported feeling it was his “best day ever” due to a decision to start his own company. His affect was labile, fluctuating with speech content. Speech was loud and pressured at times, quickly regaining composure. He exhibited flight of ideas and loosening of associations, abruptly shifting topics. Mr. Davis expressed grandiose delusions regarding sexual and athletic performance. He denied auditory hallucinations and displayed orientation to time and place. He denied suicidal and homicidal ideation but refused memory or intellectual testing. Reliability, judgment, and insight were impaired.

Assessment (A): Differential Diagnoses:

Major Depressive Disorder, recurrent, without psychotic features (F33.4)

Bipolar Disorder with Psychotic Features (F31.6)

Schizophrenia (F20.0)

Definitive Diagnosis: Major Depressive Disorder, recurrent, without psychotic features (F33.4) Generalized Anxiety Disorder (F41.1)

Plan (P):

Pharmacological Treatment:

Continue Fluoxetine, increasing dose to 20mg daily

Psychotherapy:

Continue outpatient counseling: partial inpatient program with individual and group sessions

Modality: Cognitive Behavioral Therapy (CBT)

Education:

Discussed smoking cessation options

Reviewed medication side effects and importance of adherence

Follow-up:

Schedule appointment in one week or earlier if depressive symptoms worsen

Referrals:

None at this time

Summary of Warning Signs and Treatment Plan Rationale:

Warning Signs of Suicidality: While Mr. Davis denies current suicidal ideation, several concerning factors warrant close monitoring:

Recent discharge from inpatient psychiatric care following a suicide attempt

Ongoing depressive symptoms despite some improvement

Presence of psychotic features (grandiose delusions, flight of ideas)

Impaired judgment and insight

High anxiety levels (BAI score of 34)

Treatment Plan Rationale: The treatment plan addresses Mr. Davis’s complex presentation of Major Depressive Disorder with psychotic features and comorbid anxiety. The multifaceted approach includes:

Medication Management: Increasing fluoxetine dosage aims to further alleviate depressive and anxiety symptoms. Fluoxetine, a selective serotonin reuptake inhibitor (SSRI), has shown efficacy in treating both depression and anxiety (Cipriani et al., 2018).

Continued Partial Inpatient Program: This structured environment provides intensive support during the critical post-discharge period, reducing suicide risk and allowing for close monitoring of symptoms (Nordentoft et al., 2015).

Cognitive Behavioral Therapy (CBT): CBT is an evidence-based intervention for depression and anxiety, helping patients identify and modify negative thought patterns and behaviors (Beck & Bredemeier, 2016).

Regular Follow-up: Weekly appointments allow for close monitoring of symptom progression and medication efficacy, crucial for suicide prevention and early intervention if needed (American Psychiatric Association, 2013).

Psychoeducation: Discussing medication adherence and smoking cessation addresses potential barriers to recovery and promotes overall health, which can positively impact mental health outcomes (NICE, 2018).

This comprehensive approach targets Mr. Davis’s depressive symptoms, anxiety, and psychotic features while maintaining vigilance for any signs of increased suicide risk. The treatment plan’s flexibility allows for adjustments based on his response to interventions.

References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing.

Beck, A. T., & Bredemeier, K. (2016). A unified model of depression: Integrating clinical, cognitive, biological, and evolutionary perspectives. Clinical Psychological Science, 4(4), 596-619.

Cipriani, A., Furukawa, T. A., Salanti, G., Chaimani, A., Atkinson, L. Z., Ogawa, Y., … & Geddes, J. R. (2018). Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. The Lancet, 391(10128), 1357-1366.

National Institute for Health and Care Excellence (NICE). (2018). Depression in adults: recognition and management. NICE guideline [NG56]. London: NICE.

Nordentoft, M., Wahlbeck, K., Hällgren, J., Westman, J., Ösby, U., Alinaghizadeh, H., … & Laursen, T. M. (2015). Excess mortality, causes of death and life expectancy in 270,770 patients with recent onset of mental disorders in Denmark, Finland and Sweden. PloS one, 10(1), e0113296.

Keywords: Major Depressive Disorder, Suicide Risk Assessment, Cognitive Behavioral Therapy

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SOAP note + 1 page summary that highlights the warning signs of suicidality in the patient and why you chose the treatment plan you choose in your SOAP Note.

Review the video case: Suicide assessment of Client with initially Subtle Warning Signs of Suicide

Complete a SOAP Note as if you were the psychotherapist in the video. Then write a one page summary that highlights the warning signs of suicidality in the patient and why you chose the treatment plan you choose in your SOAP Note.
SOAP Template:
Patient Name: XXX
MRN: XXX

Date of Service: 01-27-2020

Start Time: 10:00 End Time: 10:54

Billing Code(s): 90213, 90836
(be sure you include strictly psychotherapy codes or both E&M and add on psychotherapy codes if prescribing provider visit)

Accompanied by: Brother

CC: follow-up appt. for counseling after discharge from inpatient psychiatric unit 2 days ago

HPI: 1 week from inpatient care to current partial inpatient care daily individual psychotherapy session and extended daily group sessions

S- Patient states that he generally has been doing well with depressive and anxiety symptoms improved but he still feels down at times. He states he is sleeping better, achieving 7-8 hours of restful sleep each night. He states he feels the medication is helping somewhat and without any noticeable side-effects.
Crisis Issues: He states he has no suicide plan and has not thought about suicide since the recent attempt. He states has no access to prescription medications, other than the fluoxetine. He believes the classes he participated in while inpatient have helped him with coping mechanisms.
Reviewed Allergies: NKA
Current Medications: Fluoxetine 10mg daily
ROS: no complaints

O-
Vitals: T 98.4, P 82, R 16, BP 122/78
PE: (not always required and performed, especially in psychotherapy only visits)
Heart- RRR, no murmurs, no gallops
Lungs- CTA bilaterally
Skin- no lesions or rashes
Labs: CBC, lytes, and TSH all within normal limits

Results of any Psychiatric Clinical Tests: BAI=34

MSE:
Gary Davis, a 36-year-old white male, was disheveled and unkempt on presentation to the outpatient office. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age. During the interview, he was attentive and calm. He was impatient, but polite in his interactions with this examiner. Mr. Davis reported that today was the best day of his life, because he had decided he was going to be better and start his own company. His affect was labile, but appropriate to the content of his speech (i.e., he became tearful when reporting he had “bogeyed number 15” in gold yesterday). His speech was loud, pressured at times then he would quickly gain composure to a more neutral tone. He exhibited loosening of associations and flight of ideas; he intermittently and unpredictably shifted the topic of conversation from golf, to the mating habits of geese, to the likelihood of extraterrestrial life. Mr. Davis described grandiose delusions regarding his sexual and athletic performance. He reported no auditory hallucinations. He was oriented to time and place. He denied suicidal and homicidal ideation. He refused to participate in intellectual- or memory-related portions of the examination. Reliability, judgment, and insight were impaired.

A – with (ICD-10 code)
Differential Diagnoses:
1. choose 3 differential diagnoses
2.
3.
Definitive Diagnosis:
Major Depressive Disorder, recurrent, without psychotic features F33.4
Generalized Anxiety Disorder F41.1

P- Continue Fluoxetine increasing dose to 20mg.

Continue outpatient counseling: partial inpatient program continued with individual and group sessions

Non-pharmacological Tx: Psychotherapy Modality used: CBT
Pharmacological Tx: (be specific and give detailed Rx information)
Education: discussed smoking cessation
Reviewed medication side effects and adherence importance
Follow-up: in one week or earlier if any depressive symptoms worsen.
Referrals: none at this time

Grading Rubic:
Assignment Criteria Level III Level II Level I Not Present
Criteria 1 Level III Max Points
Points: 8 Level II Max Points
Points: 6.4 Level I Max Points
Points: 4.8 0 Points
Subjective Information
● Complete and concise summary of pertinent information. ● Well organized; partial but accurate summary of pertinent information (>80%). ● Poorly organized and/or limited summary of pertinent information (50%-80%); information other than “S” provided. ● Does not meet the criteria
Assignment Criteria Level III Level II Level I Not Present
Criteria 2 Level III Max Points
Points: 8 Level II Max Points
Points: 6.4 Level I Max Points
Points: 4.8 0 Points
Objective Information
● Complete and concise summary of pertinent information. ● Partial but accurate summary of pertinent information (>80%). ● Poorly organized and/or limited summary of pertinent information (50%-80%); information other than “O” provided. ● Does not meet the criteria
Assignment Criteria Level III Level II Level I Not Present
Criteria 3 Level III Max Points
Points: 8 Level II Max Points
Points: 6.4 Level I Max Points
Points: 4.8 0 Points
Assessment: Problem Identification and Prioritization ● Complete problem list generated and rationally prioritized; no extraneous information or issues listed.

● Most problems are identified and rationally prioritized, including the “main” problem for the case (>80%). ● Some problems are identified (50%-80%); incomplete or inappropriate problem prioritization; includes nonexistent problems or extraneous information included. ● Does not meet the criteria
Criteria 4 Level III Max Points
Points: 8 Level II Max Points
Points: 6.4 Level I Max Points
Points: 4.8 0 Points
Assessment: Assessment of Current Psychiatric & Medical Condition(s) or Drug Therapy-related Problem ● An optimal and thorough assessment is present for each problem ● An assessment is present for each problem listed but not optimal ● Assessment is present for 50-80% of problems ● Does not meet the criteria

Assignment Criteria Level III Level II Level I Not Present
Criteria 5 Level III Max Points
Points: 6 Level II Max Points
Points: 4.8 Level I Max Points
Points: 3.6 0 Points
Assessment: Treatment Goals ● Appropriate and relevant therapeutic goals for each identified problem. ● Appropriate therapeutic goals for most identified problems (>80%). ● Appropriate therapeutic goals for a few identified problems (50%-80%). ● Less than 50% of problems have appropriate therapeutic goals.
Assignment Criteria Level III Level II Level I Not Present
Criteria 6 Level III Max Points
Points: 6 Level II Max Points
Points: 4.8 Level I Max Points
Points: 3.6 0 Points
Plan: Treatment Plan ● Specific, appropriate and justified recommendations (including drug name, strength, route, frequency, and duration of therapy) for each identified problem are included. ● Includes most of the requirements for each identified problem (>80%). ● Incomplete and/or inappropriate for a few identified problems (50%-80%); information other than “P” provided. ● Less than 50% of problems have an appropriate and complete treatment plan.
Criteria 7 Level III Max Points
Points: 6 Level II Max Points
Points: 4.8 Level I Max Points
Points: 3.6 0 Points
Plan: Counseling, Referral, Monitoring & Follow-up ● Specific patient education points, monitoring parameters, follow-up plan and (where applicable) referral plan for each identified problem. ● Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for >80% of identified problems. ● Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for a few identified problems (50%-80%). ● Less than 50% of problems include appropriate counseling, monitoring, referral and/or follow-up plan.
Maximum Total Points 50 40 30
Minimum Total Points 41 points minimum 31 points minimum 1 point minimum