Develop a Focused SOAP Note

Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:
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 the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.
Reflection notes: What would you do differently with this patient if you could conduct the session again? Discuss what your next intervention would be if you could follow up with this patient. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion, and disease prevention, taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).
3 APA FORMAT REFERENCES
HOW TO ANSWER
S: Subjective
Chief Complaint: Describe the patient’s main reason for seeking psychiatric evaluation.
History of Present Illness (HPI): Include the duration and severity of symptoms, any triggering events, and the impact on the patient’s daily life.
Past Psychiatric History: Document any previous psychiatric diagnoses, treatments, hospitalizations, or therapies.
Medical History: Note any relevant medical conditions or medications.
Social History: Include information about the patient’s living situation, occupation, support system, and substance use history.
Family History: Mention any family history of psychiatric or medical conditions.
Patient’s Perception: Record the patient’s thoughts and feelings about their condition.
O: Objective
Mental Status Examination (MSE): Document the patient’s appearance, behavior, speech, mood, affect, thought process, thought content, perception, cognition, insight, and judgment.
Physical Examination (if applicable): Note any physical findings related to the chief complaint.
Assessment Tools: Include any assessment tools or scales used (e.g., PHQ-9 for depression, GAD-7 for anxiety).
A: Assessment
Differential Diagnoses: List at least three possible psychiatric diagnoses based on the information gathered. Present them in order of priority.
Differential Diagnosis 1: Include supporting evidence and compare it to DSM-5-TR criteria.
Differential Diagnosis 2: Include supporting evidence and compare it to DSM-5-TR criteria.
Differential Diagnosis 3: Include supporting evidence and compare it to DSM-5-TR criteria.
Pertinent Positives: Highlight specific symptoms or behaviors that support each differential diagnosis.
Pertinent Negatives: Note any symptoms or criteria that are absent but expected in a particular diagnosis.
Primary Diagnosis: Explain the critical-thinking process that led to selecting the primary diagnosis. Mention why other differentials were ruled out.
P: Plan
Psychotherapy: Outline the plan for psychotherapy or counseling.
Treatment and Management: Describe pharmacological and non-pharmacological treatments. Discuss their risks and benefits.
Alternative Therapies: Mention any complementary or alternative therapies considered.
Follow-Up: Provide parameters for follow-up appointments and assessments.
Health Promotion: Suggest one health promotion activity tailored to the patient’s needs.
Patient Education: Outline a patient education strategy to help the patient understand their condition, treatment options, and self-care.
R: Reflection Notes
Reflect on the session, considering what you might do differently or what interventions you would follow up with.
Discuss any legal/ethical considerations related to the patient’s case.
Address health promotion and disease prevention, considering patient factors, past medical history, and risk factors.
Please note that the SOAP note should be completed based on a real patient encounter and should adhere to ethical and legal guidelines regarding patient privacy and consent. Additionally, it should be reviewed and signed by the healthcare provider who conducted the assessment.