PRAC 6665 Week 9 Focused SOAP Note and Patient Case Presentation
At your practicum site, you have been strengthening your communication, assessment, diagnostic reasoning, and treatment skills. This week, you highlight these skills as you complete a focused SOAP note and present a patient case in a video, just as you did in Week 3 and Week 7. You also continue to track your clinical hours and patients in Meditrek.
- Describe clinical hours and patient encounters
- Assess patients across the lifespan in mental health settings
- Formulate differential diagnoses for patients across the lifespan in mental health settings
- Develop plans of care for patients across the lifespan in mental health settings
- Advocate health promotion and patient education strategies across the lifespan
- Develop a case study presentation based on a clinical patient
- Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
- Chapter 32, “How to Educate Your Patient” Meditrek https://edu.meditrek.com/Default.html
Note: Use this link to log into Meditrek to report your clinical hours and patient encounters.
Assignment 1: Clinical Hour And Patient Logs
Clinical Hour Log
For this course, all practicum activity hours are logged within the Meditrek system.
Hours completed must be logged in Meditrek within 48 hours of completion in order to be counted.
You may only log hours with Preceptors that are approved in Meditrek. Students with catalog years before Spring 2018 must complete a minimum of 576 hours of supervised clinical experience (144 hours in each practicum course). Students with catalog years beginning Spring 2018 must complete a minimum of 640 hours of supervised clinical experience (160 hours in each practicum course).
Each log entry must be linked with an individual practicum Learning Objective or a graduate Program Objective. You should track your hours in Meditrek as they are completed.
Your clinical hour log must include the following:
- Clinical Faculty
- Total Time (for the day)
- Notes/Comments (including the objective to which the log entry is aligned)
Throughout this course, you will also keep a log of patient encounters using Meditrek. You must record at least 80 encounters with patients by the end of this practicum (40 children/adolescents and 40 adult/older adults).
The patient log must include the following:
- Clinical Faculty
- Patient Number
- Client Information
- Visit Information
- Practice Management
- Treatment Plan and Notes: You must include a brief summary/synopsis of the patient visit. This does not need to be a SOAP note, however the note needs to be sufficient to remember your patient encounter.
By Day 7 of Week 9
Record your clinical hours and patient encounters in Meditrek.
Assignment 2: Focused SOAP Note and Patient Case Presentation
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.
- Review the Kaltura Media Uploader resource in the left-hand navigation of the classroom 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.
- All SOAP notes must be signed, and each page must be initiated by your Preceptor. Note: Electronic signatures are not accepted.
- When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initiated and signed by your Preceptor.
- You must submit your SOAP note using SafeAssign. Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.
- 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.
Record yourself presenting the complex case study for your clinical patient. In your presentation:
- Dress professionally with a lab coat 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 symptomatology 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: What was your plan for psychotherapy (include one health promotion activity and patient education)? What was 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.
- 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.
By Day 7 of Week 9
Submit your Video and Focused SOAP Note Assignment. You must submit two files for the note, including a Word document and scanned PDF/images of each page that is initiated and signed by your Preceptor.