FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION
PART 1
For this Assignment, you will document information about a patient that you examined during the last 3 weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient. Be sure to incorporate any feedback you received on your Week 3 and Week 7 case presentations into this final presentation for the course.
TO PREPARE
- Review the Kaltura button from the Classroom Support Center (accessed via the Help button) for help creating your self-recorded Kaltura video.
- Select a child or adolescent patient that you examined during the last 3 weeks who presented with a disorder for which you have not already created a Focused SOAP Note in Weeks 3 or 7. (For instance, if you selected a patient with anorexia nervosa in Week 7, you must choose a patient with another type of disorder for this week.)
- 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.
- Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record.
- Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
- Ensure that you have the appropriate lighting and equipment to record the presentation.
THE ASSIGNMENT
Record yourself presenting the complex case for your clinical patient.
Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video.
In your presentation:
- Dress professionally and present yourself in a professional manner.
- Display your photo ID at the start of the video when you introduce yourself.
- Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
- Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
- Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
- Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide:
- 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 their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.
- Plan: In your video, describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session?
- In your written plan include all the above as well as include one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
- Reflection notes: What would you do differently with this patient if you could conduct the session over? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.
Expert Solution Preview
Introduction:
As a medical professor responsible for creating assignments and evaluating student performance, I designed and conducted lectures, examinations, and assignments for medical college students. One of the assignments that I created was a Focused SOAP Note and Patient Case Presentation. This assignment aimed to assess the students’ ability to document and present complex cases in a professional manner, while incorporating evidence-based practice and demonstrating critical thinking skills. Here is how the assignment was structured and what the students were required to do.
Answer:
The Focused SOAP Note and Patient Case Presentation assignment required students to document information about a patient they examined within the last 3 weeks. The students were instructed to use the provided Focused SOAP Note Template to create a comprehensive note on the patient’s condition. They were also required to incorporate at least five scholarly resources to support their assessment, diagnosis, and treatment planning.
Based on the SOAP note, students were then asked to develop and record a video case study presentation. It was essential for students to present the full complex case study, including the chief complaint, history of present illness, past psychiatric and medical history, mental status examination results, differential diagnoses, primary diagnosis, treatment plan, and follow-up plan.
The video presentation was not meant to be a reading of the written evaluation but rather a simulation of a case consultation with a colleague. Students were expected to dress professionally, display their photo ID at the beginning of the video, and adhere to HIPAA principles by not disclosing any patient identifying information.
In their presentation, students were required to be succinct and not exceed 8 minutes. They needed to address subjective information provided by the patient, objective observations made during the assessment, assessment results including differential diagnoses and primary diagnosis, and the treatment plan supported by evidence-based practice. The students were also asked to include a discussion on social determinants of health related to the case and suggest health promotion activities and patient education considerations.
Finally, students were asked to reflect on their session and discuss what they would do differently, and if a follow-up was conducted, they were to evaluate the success of the interventions. If no follow-up was possible, students were expected to propose their next intervention.
Overall, this assignment aimed to assess students’ ability to effectively document and present complex cases while incorporating evidence-based practice, critical thinking, and professionalism in their video presentation.
