Week 7 – focused soap note -personality and paraphilic disorders

  

THE ASSIGNMENT: FOCUSED SOAP NOTE 

Personality and Paraphilic Disorders

To prepare

  • Select a child/adolescent      patient from      your clinical experience that presents with a significant concern. Create      a focused SOAP note for this patient using the template in the      Resources. 
  • Your presentation should      include objectives for your audience, at least three possible discussion      questions/prompts for your classmates to respond to, and at least five      scholarly resources from 2018-2022 to support your diagnostic      reasoning and treatment plan.
  • Be succinct in your presentation,      and specifically address the following for the patient, using your SOAP      note as a guide.
    • Subjective: What details did the       patient provide regarding their chief complaint and symptomology to       derive your differential diagnosis? What is the duration and severity of       their symptoms? How are their symptoms impacting their functioning in       life?
    • Objective: What observations did you       make during the psychiatric assessment? 
    • Assessment: Discuss their mental       status examination results. What were your differential diagnoses?       Provide a minimum of three possible diagnoses and why you chose them.       List them from highest priority to lowest priority. What was your primary       diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic       criteria and is supported by the patient’s symptoms.
    • Plan: What was your plan       for psychotherapy (include one health promotion activity and patient       education)? What was your plan for treatment and management, including       alternative therapies? Include pharmacologic and nonpharmacologic       treatments, alternative therapies, and follow-up parameters, as well as a       rationale for this treatment and management plan.  Discuss an       identified social determinate of health impacting this patient’s mental       health status and provide your recommendation for a referral to assist       this patient in meeting this identified need (students will need to       conduct research on this topic both in the literature and for community       resources).
    • Reflection notes: What would you do       differently with this patient if you could conduct the session       again? If you are able to follow up with your patient, explain       whether these interventions were successful and why or why not. If you were       not able to conduct a follow-up, discuss what your next intervention       would be.
    • Case Formulation

      

REQUIRED LEARNING RESOURCES

Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.

  • Chapters      31, “Assessing Personality Disorders”
  • Chapter      32, “How to Educate Your Patient”

https://health.gov/healthypeople/priority-areas/social-determinants-health

https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bpd.pdf

https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bpd-watch.pdf

https://www.youtube.com/watch?v=YOV61lKxqxY

https://www.youtube.com/watch?v=0TtryBLokZc







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