FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION, PART 1
Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you examined during the last three weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.
Family Therapy: the family members involved in today’s therapy session are S.O (Mother), K.C(Father), and T.A (son). T.A is a 12 years old Caucasian boy who apparently became moody and refuses to talk to both of his parents because his parents are getting a divorce. Other symptoms parents noticed from T.A are Mood swings, Fear, Social withdrawal, Flat affect, neglected appearance, Feeling of anger, and lost interest in favorite activities. Father and mother argue every day in front of T.A. T.A was an A student in his class but now perform poorly in all his classes. Parents express concern that they think their son is depressed and they will like him to express his feeling about their divorce. Looking into his chat, T.A does not have any medical or psychiatric conditions. He takes only one a day multivitamin. The therapist diagnosed T.A of severe depression. The treatment plan for T.A is to establish coping skills for his parent separation, to be able to express his feelings with his family, to do at least two interesting activities of his choice every day. The therapist scheduled T.A to come for every week’s session until positive changes are seen.
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