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Focused SOAP Note for Anxiety & PTSD
Focused SOAP Note for Anxiety & PTSDFocused SOAP Note for Anxiety & PTSDIn assessing
patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders,
you will continue the practice of looking to understand chief symptomology in order to
develop a diagnosis. With a differential diagnosis in mind, you can then move to a treatment
and follow-up plan that may involve both psychopharmacologic and psychotherapeutic
approaches. asCase Study—-Dev Coddoba- See Video transcriptionIn assessing patients
with anxiety, obsessive-compulsive, and trauma and stressor-related disorders, you will
continue the practice of looking to understand chief symptomology in order to develop a
diagnosis. With a differential diagnosis in mind, you can then move to a treatment and
follow-up plan that may involve both psychopharmacologic and psychotherapeutic
approaches. a In this Assignment, you use a case study to develop a focused SOAP note
based on evidence-based approaches.To PrepareReview this week’s Learning Resources.
Consider the insights they provide about assessing and diagnosing anxiety, obsessive
compulsive, and trauma-related disorders.Review the Focused SOAP Note template, which
you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar
provided as a guide for Assignment expectations.Review the video, Case Study: Dev
Cordoba. You will use this case as the basis of this Assignment. In this video, a Walden
faculty member is assessing a mock patient. The patient will be represented onscreen as an
avatar.Consider what history would be necessary to collect from this patient.Consider what
interview questions you would need to ask this patient.The AssignmentDevelop a Focused
SOAP Note, including your differential diagnosis and critical-thinking process to formulate a
primary diagnosis. Incorporate the following into your responses in the
template: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
the patient’s mental status examination results. What were your differential diagnoses?
Provide a minimum of three possible diagnoses with ing evidence, listed in order from
highest priority to lowest priority. Compare the DSM-5 diagnostic criteria for each
differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to
find an accurate diagnosis. Explain the critical-thinking process that led you to the primary
diagnosis you selected. Include pertinent positives and pertinent negatives for the specific
patient case.Plan: What is your plan for psychotherapy? What is 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. Also incorporate one health promotion
activity and one patient education strategy. Focused SOAP Note for Anxiety &
PTSDReflection notes: What would you do differently with this patient if you could conduct
the session again? Discuss what your next intervention would be if you could follow up with
this patient.?Also include in your reflection a discussion related to legal/ethical
considerations (demonstrate critical thinking beyond confidentiality and consent for
treatment!), health promotion, and disease prevention, taking into consideration patient
factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic,
cultural background, etc.).Provide at least three evidence-based, peer-reviewed journal
articles or evidenced-based guidelines that relate to this case to your diagnostics and
differential diagnoses. Be sure they are current (no more than 5 years old).SOAP TEMPLATE
attached. Medication list . Review the FDA-approved use of the following medicines related
to treating anxiety disorders, OCD, PTSD, and related disorders:AnxietyGeneralized anxiety
disorderPanic disorderalprazolamORDER NOW FOR CUSTOMIZED, PLAGIARISM-FREE
PAPERS

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Focused SOAP Note for Anxiety PTSD.docx

  • 1. Focused SOAP Note for Anxiety & PTSD Focused SOAP Note for Anxiety & PTSDFocused SOAP Note for Anxiety & PTSDIn assessing patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders, you will continue the practice of looking to understand chief symptomology in order to develop a diagnosis. With a differential diagnosis in mind, you can then move to a treatment and follow-up plan that may involve both psychopharmacologic and psychotherapeutic approaches. asCase Study—-Dev Coddoba- See Video transcriptionIn assessing patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders, you will continue the practice of looking to understand chief symptomology in order to develop a diagnosis. With a differential diagnosis in mind, you can then move to a treatment and follow-up plan that may involve both psychopharmacologic and psychotherapeutic approaches. a In this Assignment, you use a case study to develop a focused SOAP note based on evidence-based approaches.To PrepareReview this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing anxiety, obsessive compulsive, and trauma-related disorders.Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.Review the video, Case Study: Dev Cordoba. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.Consider what history would be necessary to collect from this patient.Consider what interview questions you would need to ask this patient.The AssignmentDevelop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template: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 the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with ing evidence, listed in order from highest priority to lowest priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.Plan: What is your plan for psychotherapy? What is your plan for treatment and
  • 2. 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. Also incorporate one health promotion activity and one patient education strategy. Focused SOAP Note for Anxiety & PTSDReflection notes: What would you do differently with this patient if you could conduct the session again? Discuss what your next intervention would be if you could follow up with this patient.?Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion, and disease prevention, taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).SOAP TEMPLATE attached. Medication list . Review the FDA-approved use of the following medicines related to treating anxiety disorders, OCD, PTSD, and related disorders:AnxietyGeneralized anxiety disorderPanic disorderalprazolamORDER NOW FOR CUSTOMIZED, PLAGIARISM-FREE PAPERS