Unit 6-Clinical SOAP Note on Schizoaffective disorder. Due 2-15-25.
Instructions
Each week students will choose one patient encounter to submit a Follow-up SOAP note for review.
The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.
Note: Grades of Incomplete on this assignment will result in a clinical failure.
All work should be original and submitted as a Word document unless otherwise indicated in the assignment instructions. ALL assignments need to be APA 7 format and accompanied title page in APA 7th edition format in order that the work would be properly identified for the student, the course, and the assignment. Work submitted without a title page will receive a grade of 0.
Upload note to TurnItIn plagiarism checker for grade submission.
Subjective
Patient Verification
Name: M. D.
DOB: 12/2/2004
Demographics: 20-year-old
Gender Identifier Note: Male
Chief Complaint (CC): “I’m struggling to stay focused at work and college, and I’m behind on assignments.”
HPI: M. D. is a 20-year old male, college student diagnosed with ADHD, predominantly inattentive type at age 18. Two months ago, he was started on methylphenidate (Ritalin) at an initial dose of 10 mg once daily. According to him, he experienced a mild improvement in his focus during the first few weeks of treatment but his distractibility, procrastination and completing assignments remain problematic. He often forgets normal instructions at his part time job as a retail assistant. M. D. has no major side effects from his medication, with stable sleep and appetite.
SOAP Note on Schizoaffective Read More