Writing treatment note

NU-664C-02-23PCS3 FamilyPsychiatric Ment.Hlth I

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Week 6 Discussion 1: Writing Treatment Notes

To do: Make forum posts: 1

Value: 100 points

Due: In an effort to facilitate scholarly discourse, create your initial post by Day 4, and reply to at least two of your classmates, on two separate days, by Day 7.

Grading Category: Discussions

Note: In this type of discussion, you will not see the responses of your classmates until after you have posted your own response to the question below.

Initial Post

Watch the following video:

Psychiatric Interview and Mental Status Exam (25:06 minutes)

Psychiatric Interview and Mental Status Exam Video Transcript

  1. Using the readings and references, write a complete SOAP note for this patient in the proper format.
  2. Post the SOAP note to this discussion board for your peer review.
  3. Your post should include a subjective and objective section with correct patient information, an explanation of differential diagnoses, and a comprehensive treatment plan which incorporates both psychosocial interventions as well as a medication plan, if indicated, with collateral information and patient education.
  4. Use appropriate scholarly references and APA format.
  5. Use the SOAP note template found in the Week 6: Learning Materials for your submission.

Replies

Reply to at least two of your classmates. In your reply posts, critique the plan by answering the following questions:

  • Do you agree or disagree with the plan?
  • Is anything missing from the plan?
  • Compare your peer’s plan to yours. What are the advantages and disadvantages of each?
  • Your response should include evidence of review of the course material through proper citations using APA format.

Pick out an idea from your peers’ initial post that you find most interesting and tell how you will use this information in practice.

Please refer to the Grading Rubric for details on how this activity will be graded. The described expectations meet the passing level of 80%. Students are directed to review the Discussion Grading Rubric for criteria which exceed expectations.     

 

 

 

Primary Care of the Psychiatric Mental Health Client I

Psychiatric Interview and Mental Status Exam Video Transcript

Georgianna Shea, Case Study 2

Georgina: Hi, Cory. Case two. My name is Georgina Shay. I’m a DNP nursing student at UMass. How are you doing today?

Cory: Okay.

Georgina: I’m going to go over a few things first. I already spoke with your mom. We’ve gone over a few things and I’ve given her some paperwork that talks about confidentiality. I want you to look over these as well. While we’re here, it gives me permission to talk to you and provide treatment options if needed. Whatever we talk about today will remain confidential unless I feel like you say something that would hurt yourself or hurt others. Then we’ll have to go into it a little further. Okay, so I talked to your mom already and she says that you’re not doing too well in school.

Cory: Yeah. That’s true.

Georgina: What’s happening in school?

Cory: Well I mean my grades have just been getting worse. I don’t really know. They’re just getting worse every semester, so I don’t know.

Georgina: She says your grades are falling. Do you think so?

Cory: Yeah. According to the report card, they’re definitely getting worse every semester. I haven’t failed anything yet, I don’t think.

Georgina: What grade of school are you in?

Cory: I’m a sophomore. I barely made it to sophomore year, though. I almost did fail some classes last year, but I’m a sophomore in high school.

Georgina: What was happening in your classes last year?

Cory: I just wasn’t doing the homework or forgetting to do the homework, not studying, studying sometimes. Then just in my main class, just … I don’t know. Not paying attention.

Georgina: Do you feel like your classes are too easy for you?

Cory: No. Now it’s just I just can’t concentrate, I guess. I don’t know.

Georgina: Are they too hard?

Cory: No. I can do the quizzes and stuff. It’s not like I need extra help or anything. I don’t know. Sometimes I miss some stuff because I don’t look at the board or I don’t take the right paper home, so I can’t do the homework. Yeah. It’s more than just me, I think. I don’t think it’s they’re too easy or too hard. It’s just for me, it’s not working.

Georgina: Are there any classes that you really like?

Cory: Well, yeah. I like a couple classes, but mom says they’re not really real classes for high school. They’re like woodshop, gym. She’s more worried about history, math. You know, the normal classes.

Georgina: Why do you think you like woodshop and gym so much?

Cory: I mean gym because I love sports. You’re not always doing sports, but you’re not just sitting there all day for the whole class. You can move around and do stuff. Woodshop, I like to work with my hands and build things, learn new things. I’m always (inaudible 03:15) class and that’s why my GPA looks okay-ish sometimes, because I do good in those classes. Like I said, those aren’t the main classes. Those don’t really count.

Georgina: Do you feel like you’re struggling in school?

Cory: Yeah. In comparison to other people, I guess, in my class. Yeah. I mean my teachers say … They don’t say stupid, but they say I make careless mistakes. I don’t pay attention. I don’t take notes. They tell me, “Stop doodling. Stop talking.” I want to do better, I guess. It’s just I don’t know how, I guess. I don’t know.

Georgina: Do you have a lot of friends in school?

Cory: Yeah. I get along with a lot of people mostly out of my class. I have like two or three friends or something. I always have someone to talk to or something. Yeah.

Georgina: Do you ever play any sports or extracurricular activities?

Cory: I wish. I’m not allowed to since starting high school because my grades have just been going down. I used to play basketball, baseball all the time. I played like I said ’til high school and then mom said I’m not eligible to play until I have a better GPA. I couldn’t try out. It pisses me off. I want to play. The coaches said they wanted me to play. It’s just mom won’t sign the papers, so I can’t play. I can’t play.

Georgina: Did you have any struggles in school before this year?

Cory: Yeah. I’ve always not done the best. I never had straight As or straight As and Bs or anything like that, but I just get by and stuff. I never stay back or need to go to a special classroom or anything like that. It’s just more like my grades are whatever. Bs, Cs. Every now and then I get a D, but they’ve just been getting worse every year.

Georgina: Are there any other classes that you’re really interested in besides woodshop and gym?

Cory: I guess not really. I don’t know. I know (inaudible 05:39) grow up to be a carpenter or a gym teacher, so I probably should pick something, but I don’t know. Math. I’ve always had trouble with math, so I don’t really like math. Reading and writing, I always get mistakes all the time. Every time I write a paper, it’s like careless mistakes. It’s all red. Redo it. I always lose that. I’m just frustrated with that. I (inaudible 06:03) everything. That’s what I thought. History. I’ve never liked history. Science. I guess science, if I had to pick something. Science is always cool. I like to experiment, like how you can do the labs and stuff, but the formulas and stuff are just too … Too detailed? I don’t know. Mom says I’m not good at details, so I forget things or even the experiments. I want to do experiments, but I [inaudible 00:06:31] everything. I want to make this reaction. I just pour the stuff together and sometimes I get in trouble. I like science, but I’m not … It’s just like every other class. I’m not good at it.

Georgina: Do you think you have trouble concentrating in school?

Cory: Oh, yeah. I can’t concentrate. If I have gym first period, that’s good, or gym and woodshop first. Then I can get some energy out and do stuff, but if I have them at the end of the day, I can’t do anything at the end of the day. I’m just sitting there, doodling. I doodle all the time. I just draw little pictures or talk to my friends, text on my phone. I don’t know. I can’t just sit there and take notes every class for 50 minutes and not be able to talk or anything. I read, go do … Walk to the bathroom, walk around the halls, meet my friends in the halls, talk to them, but I can’t do that all day. I don’t know.

I might have a class or two I can do good in and concentrate. Sometimes I have trouble slowing down or commenting. I talk too fast sometimes and I get really excited and I talk or there’s times where I just don’t talk at all because there’s nothing interesting.

Georgina: Do you feel like you daydream in school?

Cory: I don’t really daydream. I think about the stuff I would rather be doing. If that’s daydreaming, I don’t know. I think about playing sports or if there was a sports game, like baseball or something for the school, I think about what happened. I won’t be playing it. Listen to announcements happening. Yeah. I mean I’m not really looking at the board, so I guess yeah, I’m daydreaming.

Georgina: How about your classwork while you’re in school? Do you struggle with that?

Cory: I mean that’s probably where I get most of my good grade from just because it’s right there. I can ask the teacher if I need something. Sometimes we have quizzes and stuff still on the board, so I have to take notes and remember it so I can just do it. Tasks and stuff, I don’t really do that good because I don’t study or remember to study. I don’t know. Coursework is okay.

Georgina: Your mom says you don’t listen to the teachers. Do you feel like you’re not listening to the teachers?

Cory: Well I don’t know what they tell her what happens, but as far as … They want me to pay attention, take notes and be this [inaudible 00:09:10] sits in the front seat and does everything, but I’m doodling. They tell me to stop doodling and I don’t stop doodling because I don’t know what I’m supposed to do or I get out of class and go to the bathroom every day. They don’t like that. I don’t know if I’m not listened to. It’s just like I need to do something. I guess I need to do something. I can’t just sit there and watch a slideshow and take notes. I guess if they say that’s not listening, then yeah, I guess. I’m just trying to figure out what to do to stay in the room. I don’t know.

Georgina: You don’t find that classes are too hard or too easy. You just have no interest.

Cory: I guess.

Georgina: Is that what you’re saying?

Cory: Yeah. No interest or just not sustained interest, I guess. If it’s a half day, I do good on half days. Half days at school, I do okay because all the classes are shorter. (inaudible 10:12) half day. I could do really good.

Georgina: Okay. What about at home? Do you get your homework done at home or do you find that you struggle with homework also?

Cory: Did you ask my mom that?

Georgina: I did ask your mom that. I want to know what you think about that.

Cory: I’m pretty sure she probably told you the same thing I’m going to say is that she tries to get me to do homework. I can’t do anything ’til I do my homework, but I don’t do homework because by the time I get home, I’m already drained from being at school all day, trying to concentrate and being frustrated. Probably didn’t take any notes or I forgot the book. It’s always something I forget. Either I forget the book, I forget the actual sheet I’m supposed to do, I didn’t take the notes in class. It’s never complete even when I do it. It’s like what’s the point? Most of the time I don’t do my homework, which I’m sure doesn’t help my grade, but I just can’t remember to do everything, I guess. Shit I need to do to get it.

Georgina: Do you get really distracted when you’re trying to do your homework?

Cory: I guess. Yeah, because I’m home. My video games are there. My cellphone is there. Food’s there. TV is there. All these other options outside school where I have nothing. Just sit there, leave the classroom. Do I want to try to do homework that I don’t even know or do I want to do something else? Now I try to do both, play video games and read. That type of thing. Or try to eat dinner and then go do my homework at the end of the night, but I’m too tired. I have trouble with time management, too. That’s what mom says. She (inaudible 11:58) I wait ’til I’m tired so I’m not going to do it because I’m frustrated. I don’t really know.

Georgina: Okay.

Cory: I don’t know.

Georgina: Do you have any job outside of school?

Cory: No.

Georgina: No?

Cory: No. I have to get one in the summer, though, but I just turned 16 so I couldn’t get one before or anything. Sometimes me and my friends go and shovel people’s driveways and stuff in the neighborhood or rake people’s leaves and stuff. It’s not a real job, but no, I don’t have a job. Like I said, I can’t play sports, which is what I want to do. I don’t really do much at home besides during the weekend because I’m not allowed to go to friends’ houses or anything. I just chill out at home.

Georgina: How about your room at home? Do you like to keep it nice and clean or …

Cory: No.

Georgina: No?

Cory: I think it’s organized, but I know where everything is. It’s not clean like the rest of the house, but mom asks me to … Or anyone asks me, Can you go find this? I’m like, Yeah, that’s fine. I have piles of stuff. Just if someone else walked into my room, they couldn’t find it, but it’s not the worst. I have friends that have (inaudible 13:08) mine is semi-organized, at least in my head. I don’t know.

Georgina: Do you feel like you lose things a lot or do you think you’re pretty organized?

Cory: Well sometimes I lose stuff. I’ve lost a couple binders already this year. I have no idea where they are. I lost the house key twice this year. I just have no idea where it is. It’s probably in my room, mom says. To go clean my room, go find it and it not be there. I just make more copies. Yeah, I forget stuff. Sometimes I forgot my lunch at home. That happens probably once a week. Don’t know how that happens, but I forget. Like I said, with the homework, I just forget one of the three things. Notes, book or the actual homework. I forget my passwords sometimes. I don’t know.

Georgina: You seem to talk about your mom an awful lot. Can you tell me a little bit about your relationship with her?

Cory: Yeah, just because mom is always on me about everything. She’s the reason I’m here. Everything comes back to her wanting me to do better. I mean she’s my mom, so she wants me to do better, which I understand. She gets upset with me and frustrated with me and whatever. I didn’t decide to do this on purpose. Sometimes she makes me feel like I’m choosing to do bad or not going to listen or I’m not doing homework. I’m not choosing to do that. It just doesn’t work sometimes for me, so I get frustrated with her and she gets frustrated with me. We used to be closer when I was able to play sports. I’m upset that I can’t play sports now, so obviously that makes it so we disagree more often because I want to play sports. She won’t let me play sports. She said if I come here and figure stuff out, then maybe I could play sports. That’s why I’m here. I want to play sports again, you know?

Georgina: Do you feel like you disappoint your mother?

Cory: Yeah. She tells me all the time I disappoint her. All the coaches at the high school said they want me to play. My dad’s mad that I can’t play because mom is saying that I have to do better in school. She said she’s disappointed so I can’t play. Yeah, I already know I disappoint her, but now I’m disappointed [inaudible 00:15:29] can’t play sports. That’s what everyone thinks I should be doing and what I want to do.

Georgina: How does that make you feel, knowing that you’re disappointing her?

Cory: I guess I’m sad that I’m disappointing her, but I’m more sad that I can’t play sports (inaudible 15:46) these are kids that I’ve played sports with my whole life. We were on the same teams during traveling teams. We did everything together and now the past few years or year and a half or whatever it is, I haven’t been able to play. I’m probably not going to play next year. I’m not going to just be able to join JV or varsity my junior year. It’s hard to deal with not being able to play sports.

Georgina: You talked about your mom and your dad. Do you live with both parents?

Cory: Yeah.

Georgina: Do you have any siblings?

Cory: Well I have one sister, but she doesn’t live with us all the time because she’s in college. She’s only there during winter break or summer break or something. Mostly just me and my mom. We don’t have any pets or anything. It’s mainly just us. My parents and me.

Georgina: What do you like to do for fun at home?

Cory: Well I can’t do anything really during the week because I don’t have good grades, so I just play video games or I guess call my friends to hang out and go online, go on my phone to play games, go outside and play. On weekends, I hang out with my friends still. We play sports outside. We play basketball, but that’s really it. We hang out with (inaudible 17:04) sometimes, but not very much.

Georgina: Sounds like you really like outdoor things.

Cory: Mm-hmm (affirmative). Yeah.

Georgina: Things that get you moving.

Cory: Yeah. Like I said, I always have (inaudible 17:15) sports. I try to be active, try to do stuff outside, but mowing the lawn or just doing anything outside. I don’t like just sitting still. I don’t like going to the movies or stuff like that. Mom asks me if I want to go to the movies. I’m like, “I don’t want to sit there for that long and do nothing.” Or I play video games. Just anything. Hiking, swimming, summer. I love summer because no school and you can just do whatever you want. Mom says summer only comes if you do good in school. If not, you’re going to school. It’s like what am I supposed to do? I don’t know what I’m supposed to do.

Georgina: How long do you usually play video games for when you play?

Cory: Well I’m not supposed to play that much, but if me and my friends are online together or something, playing … I don’t know. Sports games or Call of Duty or something. We’re all playing stuff. I’ll play for a couple hours. Weekends, probably two to three hours at night just because there’s nothing else to do. We’ll play online all night or something. All when my friends are on and stuff.

Georgina: Do you feel like you can sit and concentrate on that for a while?

Cory: I mean that’s fun. Yeah. I mean that’s different I think just for playing. I have the gaming chairs, the controllers, the headset. You’re not just sitting there, not moving or anything. I’m using my hands and talking. I’m able to just do whatever I want to do. I don’t know. That’s different I guess for me than just sitting in school, but I don’t know. Maybe it’s not.

Georgina: How do you feel like you’re sleeping at night?

Cory: I don’t know. I guess it’s okay.

Georgina: Do you feel like you’re rested in the morning when you go to sleep?

Cory: Yeah, I guess. Sometimes I’m tired if I’m up late, playing video games or something, or if I had trouble falling asleep. Sometimes it takes me a little bit to fall asleep. (inaudible 19:23) or something. I sleep okay, I guess.

Georgina: Do you feel like you have a lot of thoughts in your head at night and you just can’t get them to help you fall asleep?

Cory: I mean sometimes.

Georgina: Are you thinking about a lot of things and just can’t rest your head?

Cory: I think as far as my body is not tired … My body is tired. It’s just my body does … I don’t know. Especially when I can’t play sports or anything and I’m just at home all day or something. I have so much energy. It takes me awhile to calm it down. I try different things, but sometimes just … I don’t know.

Georgina: Do you feel like if you have a good night sleep, say from eight to eight, your concentration would be better at school?

Cory: No, I don’t think so. I don’t think it has anything to do with that. I’m yawning right now. I don’t think it has anything to do with the amount of sleep I get. I think it’s just school is different.

Georgina: Okay. Do you ever drink any coffee, caffeinated beverages, energy drinks?

Cory: No. I mean I don’t drink coffee. I don’t like coffee. Never have. Sometimes if I’m up, like I said, playing video games or something, I’ll drink a Monster or a Red Bull or something, but that’s not regular because I don’t know. Caffeine is not good for you when you’re a kid and stuff. It makes me even more hyper. I don’t drink that. No, I guess. I drink soda, though.

Georgina: Okay. I’m just going to ask you a few other questions now.

Cory: Yeah.

Georgina: These questions that we ask every month. We’re going to start with a couple things. Do you have any allergies that you know of?

Cory: Bees. That’s it.

Georgina: Bees. Have you ever had to be hospitalized for anything?

Cory: No. I’ve never stayed overnight in a hospital. Just bumps and bruises, sprained ankles and stuff, but that’s it.

Georgina: Okay. I’m going to ask you three words and then I’m going to have you repeat them back to me a little bit, okay?

Cory: Yeah.

Georgina: The words are green, ball, cat.

Cory: Okay. Green, ball, cat.

Georgina: Green, ball, cat. Okay. Could you spell the word “world” backwards for me?

Cory: D-L-R-O-W.

Georgina: Okay. Do you know what day it is today?

Cory: Saturday.

Georgina: Saturday. What year is it?

Cory: 2016.

Georgina: Okay. Have you ever had counseling before?

Cory: No. I’ve never been to anything like this before. I’ve been to the doctors, but no, never counseling.

Georgina: Okay. Have you ever felt sad?

Cory: Yeah. I mean I’ve felt sad before.

Georgina: Low?

Cory: Well I feel sad now that I can’t play sports and stuff, but I’ve never felt like some people get depressed or something. I never felt like that.

Georgina: Have you ever had thoughts of hurting yourself?

Cory: No.

Georgina: Or hurting anybody else?

Cory: No. I would never hurt myself or anyone else.

Georgina: Do you ever feel that you’re impulsive?

Cory: Sometimes I can be impulsive, just if I want to go get to the mall or something or I want to go play sports. Me and my friends will make plans at the last minute, but no, nothing crazy.

Georgina: Okay. Have you ever heard voices in your head that other people can’t hear?

Cory: No, I’ve never heard anything like that.

Georgina: Okay. Can you tell me those three words again?

Cory: Green, ball, cat.

Georgina: Green, ball, cat.

Cory: Yeah.

Georgina: Okay. It seems like you’re having some trouble in school. You’re not able to pay attention in class. You’re very good at sports.

Cory: Yeah.

Georgina: You really like sports. You really want to play sports again.

Cory: Absolutely.

Georgina: It sounds like you feel like you’re disappointing your mom because she doesn’t understand that you’re trying, but you just can’t seem to concentrate. Does that sound right?

Cory: Yeah. That’s just how I feel.

Georgina: Okay.

Cory: I don’t know what to do, though.

Georgina: I think what we’ll do is we’ll continue meeting, okay? I think what it sounds like is you’re having some symptoms of attention deficit hyperactivity disorder.

Cory: Okay.

Georgina: Okay. What I’ll have you do is come back and visit me again in two weeks.

Cory: Okay.

Georgina: In the meantime, I’ll have you see somebody for some extra testing.

Cory: Okay.

Georgina: Then once we get those results, come back and we’ll talk. We’ll see what other treatments are needed.

Cory: Okay.

Georgina: Get you back on that varsity team.

Cory: Okay.

Georgina: How does that sound?

Cory: I’m good with whatever will get me back on the sports team. I will do whatever, but I just hope it’s good enough for mom because I just … I want to play sports. I guess I can play basketball this year if I can get them up, but I don’t know how long it’s going to take. Whatever. I just want to play sports.

Georgina: Okay.

Cory: Okay. All right.

Georgina: Do you have anything else you want to talk about?

Cory: No. We’ll just meet again and then we’ll do the testing?

Georgina: Yeah.

Cory: Okay. Are we all set now?

Georgina: Yeah.

Cory: Okay.

Georgina: Do you have any other questions?

Cory: No. I’ll just talk to mom about it and stuff. I’m sure the testing will be fine.

Georgina: I will bring her in next and we’ll talk with you. We can all talk about it together.

Cory: Okay. Let’s do that then. That’s fine.

Georgina: All right.

Cory: Thanks.

Georgina: Sounds good.

Cory: All right. Cool.

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