Mental Health SOAP Note Research Paper

Mental Health SOAP Note Research Paper

Instructions/Descriptions

Mental Health SOAP Note Research Paper

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Subjective

Ms. Tina Jones is a 28yo pleasant AA female. She is alert, well- groomed. Speech is fluent and words are clear. Thought process are coherent, insight is good. She maintains eye contact during our interview. She presents to the clinic c/o difficult sleeping this past month, and is occurring more often this past 3 1/2 weeks. She reports feeling “nervous, excessive working before bedtime” She feels “on edge” due to lack of sleep. She sleeps an average of 4-5 hours, and is awake by 8am.

She sleeps like a “log” when she has fallen asleep. She watches tv and reads book to assist with her sleep. She does not take naps. She drinks four diet coke daily, last intake at 4pm. Social Hx: stress in her life, due to upcoming exams and job search after graduation. She has support from her family, friends and her church members whom she sees twice a week. Father passed away, felt sad, and is coping well.

No counseling, but felt she did not need one for her grieving process. Drug use: hx of the use at 20 years old: stopped. No tobacco use. ETOH: socially. She does not exercise, for she gets tired with work and school. No medications used for insomnia. ROS: Loss of appetite, probably due to her feeling tired. Has increase fatigue in the daytime.

Has changes in concentration due to fatigue. PMHX: Diabetes: no meds Asthma: on albuterol and Proventil: controlled asthma Mental health: denies depression, suicidal thoughts or homicidal ideation. no hx of anxiety except for today due to upcoming exams and future job search. Does feel her mood has been “off” and does not feel like herself. She denies tension or memory loss. Family hx: No mental illness, only Uncle with alcoholism.

HPI: Ms. Jones presents to the clinic complaining of difficulty sleeping which she notes to have started 1 month ago. She states that her sleep is “shallow and not restful”. She complains of difficult falling asleep at least 4 or 5 nights per week, but states that she able to stay asleep without difficulty. On average she sleeps 4 or hours per night and awakens at 8:00am daily. She states that she has a fairly consistent schedule on weekdays and weekends.

She does not take any prescription or over the counter sleep aids. She limits screen time prior to bed and does not ingest caffeine after 4pm daily. She endorses decreased feelings of sleepiness over t past month. She denies difficulties awaking, but does not feel res in the morning and has daytime fatigue (rates 5/10 severity), restlessness, and irritability (rates 2/10 severity). She does not ta naps.

Social History: She states that she has some stress related to the upcoming examinations and her impending job search upon graduation. She states that she has a strong support system ma up of friends and family and she is active in her church. She state that she copes with stress by staying organized. She enjoys read and watching television (1-2 hours per day).

She states that her father died in a car accident a year and a half ago, which was difficult for her and she experienced some difficulties with sleep that time as well. She denies use of tobacco. She drinks approximately 10-12 alcoholic beverages per month, but never m than 3 per sitting and does not note any impact on her sleep.

Sh has used marijuana in the past, but no current use and denies ot illicit drugs. She does not exercise regularly, but states that her jo somewhat active and she walks 5-15 minutes daily. She drinks 1 diet colas per day. Family History: Denies any history of known sleep disorders or psychiatric disorders.

Review of Systems: • General: Denies changes in weight, weakness, fever, chills, and night sweats. Does complain of increasing daytime fatigue. • Neurologic: Denies loss of sensation, numbness, tingling, tremo weakness, paralysis, fainting, blackouts, or seizures. Endorses changes in concentration and sleep.

Denies changes or difficulties coordination. • Psychiatric: States that her mood has been “off” and she does feel like herself. She does complain of increased anxiety related t upcoming exams and job search. She has no history of depression but does state that she feels helpless and notes that her performance at work and school is beginning to decline. She den tension or memory loss. No past suicide attempts. Denies suicide homicidal ideation.

Assessment

Insomnia related to anxiety Sleep disturbance related to anxiety

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Plan

Encourage a diary of her episodes of insomnia and anxiety: stating associated factors and what helps with the anxiety Offer cognitive behavioral therapy (CBT) Educate on anxiety reduction strategies including deep breathing, relaxation and guided imagery.

Offer consultation to behavioral Health Specialist Encourage diet and exercise regimen Decrease caffeine intake Offer telephone appointment to check in with her in a week Give warning signs on when to seek for help, as in inability to care for self, depression, anxiety or suicidal thoughts.

• Encourage Ms. Jones to continue to monitor symptoms and log episodes of insomnia and anxiety with associated factors and br log to next visit. • Encourage to decrease caffeine consumption and increase inta of water and other fluids. • Educate on anxiety reduction strategies including deep breathing relaxation, and guided imagery. Continue to monitor and explore need for possible referral to social work/psychiatry or pharmacal intervention.

Discuss need to maintain regular sleep and wake schedule and sleep hygiene techniques including limiting caffeine after 2pm, limiting fluids after dinner, limiting screen time or stimulating activities after 8pm, and to get out of bed if awaken in the middle the night.

Educate to limit alcohol and depressant medications (including diphenhydramine and Tylenol PM). • Educate on when to seek further or emergent care including feelings of self-harm or hopelessness. • Revisit clinic in 2-4 weeks for follow up and evaluation.

Mental Health SOAP Note Research Paper

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