Bipolar and ADHD Disorders SOAP NOTES

December 9, 2022

Bipolar and ADHD Disorders SOAP NOTES

Order Number	636738393092
Type of Project	ESSAY
Writer Level	PHD VERIFIED
Format	APA
Academic Sources	10
Page Count	3-12 PAGES

Instructions/Descriptions

Bipolar and ADHD Disorders SOAP NOTES

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Students will be required to complete one SOAP (psych) note on a patient seen in the practicum setting each week. These need to follow the guidelines for writing SOAP notes (S = Subjective, O = Objective, A = Assessment, P = Plan) and include relevant history, physical findings, assessment, and interventions.

Student is required to submit a minimum of one SOAP note in order to receive grade.

USE BIPOLAR OR ADHD with EATING DISORDER AS YOUR DSM Diagnosis

OSCE SOAP (Psych)NOTE

REQUIRED ELEMENTS OF THE SOAP (psych)NOTE

Student Name: ________________________________________Patient Initial____________

Patient Information

􀁸 Gender

􀁸 Height and Weight

􀁸 Marital status

􀁸 Occupation

􀁸 Current medication

􀁸 Past Psychiatric medication

􀁸 Allergies

Subjective:

􀁸 Chief complaint: describe the reason for the visit and chief complaint

􀁸 Describe history of present illness, including analysis of symptoms

􀁸 Medical history

􀁸 Psychiatric history (age of onset, diagnosis, previous treatments, hospitalization)

􀁸 Family history

􀁸 Psychosocial/Developmental History

􀁸 Substance Use History

􀁸 Current or Past Legal History

􀁸 Current or Past Truma

􀁸 Current or Past Abuse

􀁸 Review of Systems (no significant issues revealed, CV, Renal, GI, Hepatic, CNS, GU, CA, Metabolic, Pulm, GYN, HIV)

Objective

􀁸 Mental Staus exam

􀁸 Screening tests/symptom scales Performed

􀁸 Strengths/Limitations

􀁸 Include any objective data you have now, including labs

Assessment:

􀁸 Identify diagnosis, including differential diagnosis and rationale

􀁸 Case Formulation

Plan:

􀁸 List plan of care, including medication (Evidence Based Practice) and rationale

􀁸 Describe any needed lab work with rationale

􀁸 Identify alternatives to this plan

􀁸 Referrals

􀁸 How soon should the patient return for follow-up and why?

􀁸 Was this patient an appropriate patient for a nurse practitioner? Is a nurse practitioner the

appropriate provider of follow-up care for this patient?

􀁸 Was this a health care encounter that required consultation or collaboration with another

health care provider?

􀁸 If yes, to whom should the patient be referred? Is this type of provider available in the community?

Education:

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􀁸 What education does this patient/family need?

􀁸 What community resources are available in the provision of care for this client?

Bipolar and ADHD Disorders SOAP NOTES

RUBRIC

Excellent Quality

95-100%

Introduction

45-41 points

The context and relevance of the issue, as well as a clear description of the study aim, are presented. The history of searches is discussed.

Literature Support

91-84 points

The context and relevance of the issue, as well as a clear description of the study aim, are presented. The history of searches is discussed.

Methodology

58-53 points

With titles for each slide as well as bulleted sections to group relevant information as required, the content is well-organized. Excellent use of typeface, color, images, effects, and so on to improve readability and presenting content. The minimum length criterion of 10 slides/pages is reached.

Average Score

50-85%

40-38 points

More depth/information is required for the context and importance, otherwise the study detail will be unclear. There is no search history information supplied.

83-76 points

There is a review of important theoretical literature, however there is limited integration of research into problem-related ideas. The review is just partly focused and arranged. There is research that both supports and opposes. A summary of the material given is provided. The conclusion may or may not include a biblical integration.

52-49 points

The content is somewhat ordered, but there is no discernible organization. The use of typeface, color, graphics, effects, and so on may sometimes distract from the presenting substance. It is possible that the length criteria will not be reached.

Poor Quality

0-45%

37-1 points

The context and/or importance are lacking. There is no search history information supplied.

75-1 points

There has been an examination of relevant theoretical literature, but still no research concerning problem-related concepts has been synthesized. The review is just somewhat focused and organized. The provided overview of content does not include any supporting or opposing research. The conclusion has no scriptural references.

48-1 points

There is no logical or apparent organizational structure. There is no discernible logical sequence. The use of typeface, color, graphics, effects, and so on often detracts from the presenting substance. It is possible that the length criteria will not be reached.