SOAP Note & Safety Plan
Assignment Details
Read the case study, complete an initial assessment soap note and develop a safety plan for Jill. Add a short narrative about educating the family and patient about safety of environment and coping strategies to help the patient through any times involving suicidal thoughts or thoughts of self-harm. Consider if she should be admitted for monitoring or scheduled for more frequent follow-ups, what type of psychotherapy modality would be helpful, et cetera.
Jill is a 50-year-old woman who lives with her husband and two children (aged 20 and 18). She has come to see her PMHNP with worries about a number of health problems including extreme tiredness, agitation and pains in her chest.
SOAP Note & Safety Plan
Past history Jill has been a frequent attender at the practice over the years, often with concerns about her or her children’s health. She experienced postpartum depression with her second child. She has a history of GAD and Depression and has been on and off antidepressants for the past 30 years. When she was 23 she took an overdose following the break-up of a relationship. She had some sessions of counseling about 10 years ago that she found helpful. She was referred to a primary care mental health worker in the practice 2 years ago for help with anxiety and low mood. She had some sessions of individual guided self-help, but she found that this made no difference. She was put in touch with a voluntary sector self-help group for people with anxiety around this time – but did not pursue this.
SOAP Note & Safety Plan
She has no other health history or complaints today related to medical health, no military history. She currently takes no medications and has no allergies. She considers herself healthy as she eats a vegan diet and does walk 2 times a week around the local lake.
On examination Jill says she has always been a very ‘nervy’ person who finds dealing with everyday stresses difficult. She worries a lot about herself and her family and easily gets ‘in a state’ and assumes ‘the worst’ – for example, if family members are unwell or if they are late coming home. Sometimes things get so bad that she needs someone around her constantly to reassure her and feels that she can’t be left on her own. The intensity of these problems has varied over the years, but has become worse again during the past 8 months following her husband’s diagnosis of heart problems.
SOAP Note & Safety Plan
She has been drinking wine most evenings to try to calm herself down. More recently things have become so bad that she has sometimes felt that if she were left on her own she might harm herself. Her family has been very supportive and stayed with her during these periods until she calmed down, but is now finding this difficult to manage. Last night she had an extended period of feeling like everyone would be better off without her. She describes a plan “to drink alcohol, take some of her husband’s pain medications, start her car in the garage and pass out.” She states the only thing that ever helps her is to walk and hum to herself and in the winter she sometimes knits. APA.
Vitals:
BP: 122/68
HR: 74
R: 18
T: 97
O2: 99%
Pain: 2 on 0–10 scale
Wt.: 147
Ht.: 66”