Assignment 2: Focused SOAP Note and Patient Case Presentation To Prepare Review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded

Assignment 2: Focused SOAP Note and Patient Case Presentation

To Prepare

  • Review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
  • Select a child or adolescent patient that you examined during the last 3 weeks who presented with a disorder for which you have not already created a Focused SOAP Note in Weeks 3 or 7. (For instance, if you selected a patient with anorexia nervosa in Week 7, you must choose a patient with another type of disorder for this week.)
  • Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.Please Note:
    • All SOAP notes must be signed, and each page must be initialed by your Preceptor. Note: Electronic signatures are not accepted.
    • When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor.
    • You must submit your SOAP note using SafeAssign. Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.
  • Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record.
  • Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
  • Ensure that you have the appropriate lighting and equipment to record the presentation.

The Assignment

Record yourself presenting the complex case for your clinical patient.

Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video. 

In your presentation:

  • Dress professionally and present yourself in a professional manner.
  • Display your photo ID at the start of the video when you introduce yourself.
  • Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
  • Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
  • Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
  • Be succinct in your presentation, and do not exceed 8 minutes. 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 diagnostic criteria and supported by the patient’s symptoms.
    • Plan: In your video, describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session?
    • In your written plan include all the above as well as include one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
    • Reflection notes: What would you do differently with this patient if you could conduct the session over? 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.

Expert Solution Preview

Introduction:
In this assignment, medical college students are required to choose a child or adolescent patient that they have examined during the past three weeks, who presented with a disorder for which they have not already created a Focused SOAP Note in Weeks 3 or 7. They are required to create a Focused SOAP Note for this patient and based on it, develop a video case study presentation. In this presentation, they need to present a full complex case study of the patient, including their chief complaint, history of present illness, any pertinent past psychiatric, substance use, medical, social, family history, most recent mental status exam, current psychiatric diagnosis including differentials that were ruled out, and plans for treatment and management. Additionally, they need to include at least five scholarly resources to support their assessment, diagnosis, and treatment planning. In this article, we will discuss how medical college students can approach this assignment and create a comprehensive and effective presentation.

Question 1: How to select a patient for the assignment?

Medical college students are required to select a child or adolescent patient they have examined during the past three weeks, who presented with a disorder for which they have not already created a Focused SOAP Note in Weeks 3 or 7. If they selected a patient with anorexia nervosa in Week 7, they must choose a patient with another type of disorder for this assignment.

Question 2: What is the Focused SOAP Note, and how to create it?

A Focused SOAP Note is a documentation format that helps medical professionals to organize and document patient information efficiently. In this assignment, medical college students are required to create a Focused SOAP Note on the patient they have selected using the template provided in the Learning Resources. They can refer to the completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.

It is important to note that all SOAP notes must be signed, and each page must be initialed by the student’s Preceptor. Electronic signatures are not accepted. When submitting the note, students should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by their Preceptor. Students must submit their SOAP note using SafeAssign, and if both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.

Question 3: How to develop a video case study presentation?

Based on the SOAP note of the patient, medical college students need to develop a video case study presentation. They should take some time to practice their presentation before recording it. In their presentation, they should dress professionally and present themselves in a professional manner. They should display their photo ID at the start of the video when introducing themselves.

It is important to note that students should ensure that they do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information). They should present the full complex case study, including chief complaint, history of present illness, any pertinent past psychiatric, substance use, medical, social, family history, most recent mental status exam, current psychiatric diagnosis including differentials that were ruled out, and plans for treatment and management.

Students should report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value. They should be succinct in their presentation, and it should not exceed 8 minutes. They should specifically address the following for the patient, using their SOAP note as a guide:

– Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive their differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?

– Objective: What observations did the student make during the psychiatric assessment?

– Assessment: Discuss the patient’s mental status examination results. What were the differential diagnoses? Provide a minimum of three possible diagnoses and why they chose them. List them from highest priority to lowest priority. What was the primary diagnosis, and why? Describe how the primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.

– Plan: In the video, describe their treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on their chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of their rationale for the choice supported by valid research. What were their follow-up plan and parameters? What referrals would they make or recommend as a result of this treatment session?

In their written plan, students should include all the above as well as one social determinant of health according to the HealthyPeople 2030 (they will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, they should also provide one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health. This will demonstrate their critical thinking.

Students should also provide reflection notes on what they would do differently with this patient if they could conduct the session over. If they are able to follow up with their patient, they should explain whether these interventions were successful and why or why not. If they were not able to conduct a follow-up, they should discuss what their next intervention would be.

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