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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.

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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
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Today, a 22-year-old woman comes in for a check-up and medication management. Trichotillomania and Attention Deficit Hyperactivity Disorder (ADHD), primarily inattentive type, are the diagnoses. The patient is attentive and oriented x 4, calm and cooperative; speech is clear and coherent; well-groomed; thought process is logical and sequential; gait is normal; appearance is normal; hygiene and grooming are fair, and the patient is calm and cooperative. The patient preparing for GRE says her medications are working well and there are no side effects, that she can stay focused on studying, that she has been sleeping well, that she has a normal appetite, that she hasn’t had any anxiety or depression, that she feels stable, that she hasn’t gone to therapy, that she doesn’t pull her hair out, that she doesn’t use alcohol or drugs, that she works part-time and has enough time to study, and that she exercises 5-6 times a week. Prescriptions have been submitted to the pharmacy, and the patient will return in 6 weeks. Medications management: 20 MG Oral Capsule Amphetamine-Dextroamphetamine (Adderall XR) Extended Edition a 24-hour period Plan: Continue present meds and return to the clinic in 6 months.

 

 

 

 

 

 

Chief complaint • History of present illness (HPI) • Medications • Psychotherapy or previous psychiatric diagnosis • Pertinent histories and/or ROS 9 (9%) – 10 (10%)

The video accurately and concisely presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis.

8 (8%) – 8 (8%)

The video accurately presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis.

7 (7%) – 7 (7%)

The video presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis, but is somewhat vague or contains minor inaccuracies.

0 (0%) – 6 (6%)

The video presents an incomplete, inaccurate, or unnecessarily detailed/verbose description of the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis. Or subjective documentation is missing.

Discuss Objective data: • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history • Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses 9 (9%) – 10 (10%)

The video accurately and concisely documents the patient’s physical exam for pertinent systems. Pertinent diagnostic tests and their results are documented, as applicable.

8 (8%) – 8 (8%)

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are documented, as

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