Soap Note

The patient in this was started on Zoloft 50mg po every morning.

Kindly dont forget to answer all the prompts especially in the reflection and the plan

This case study consists of one hypothetical patient situation.

For this assignment, you will address a series of questions regarding the care of the patient. Your answers should include specific reference to relevant guidelines and other clinical information. The national guidelines should also be considered with treatment plans. You should choose a specifics for tx that may include psychotherapy modalities, specific medications with dosing, titration etc… Be sure you include patient education and safety as well in your SOAP notes.  I hope this helps. DO NOT TURN IN the SOAP NOTE TEMPLATE if used to analyze the case.  This will cause your similarity score to be very high when you copy information directly from the case.  Instead, only turn in an analysis paper of the case using the supplied paper template here.

Please use the attached SOAP note template as a guide to document the findings on this case and document the actual SOAP note in the (Week 4 NU643 Anxiety Case Study Template) 

DO NOT COPY and PASTE data directly from the case.  For this case study, we want you to summarize the information and synthesize your thoughts in APA paper format. “Synthesizing requires the reader to take that summary or retelling of the case and add in their assessments, interpretations, and connections to generate a working clinical treatment plan (classroom nook).”

Readings

• Stahl, S. (2021). Essentials of Psychopharmacology, (5th edition). United Kingdom, Cambridge University Press, ISBN: 978-1108838573.
  • Chapter 4: Psychosis, Schizophrenia, and Neurotransmitter Networks Dopamine, Serotonin and Glutamate
  • Chapter 5: Targeting Dopamine and Srotonin Receptors for Psychosis, Mood, and Beyond So Called “Antipsychotics”
• Puzantian, T. & Carlat, D. (2016).Antipsychotic Information (PDF) Medication Fact Book for Psychiatric Practice (3rd ed.). Newburyport, MA: Carlat Publishing, LLC.
• The Carlat Report: FDA Approves First Drug to Treat Tardive Dyskinesia, June 2017

Recommended

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (PDF) (5th ed.). American Psychiatric Publishing, Inc.
  • Scan pages 87–122.

Hi. This is a soap note. Please reference as needed. APA 7 format, current references. See Grading Rubric and expectations. 

See the attached 

The Mental health SOAP note is a tool utilized to guide clinical reasoning to assess, diagnosis, and develop a treatment plan for a patient based on information presented and current evaluation of the patient. These notes serve as an important source of information about the health status of the patient and can be used to communicate this status to other health care professionals.

Instructions

1. Review the following resources:

• SOAP Note Template (Word)

1. Complete the SOAP Note Questionnaire and submit to this assignment.
2.  

Complete your SOAP note based on this client interaction. Remember, the video is to provide the client’s clinical presentation to you and you will be writing the SOAP note as though you are the actual provider seeing the client.

https://symptommedia.com/arnie-core-video-opioid-use-disorder-mild/