Hello I have attached the original soap note 7 that was completed. I didn’t receive a decent grade; however, my instructor is allowing me that opportunity to pull it up. I have attached screen shots of what is required per grading rubric, as well an example from when I did week 9 soap note. The soap not 7 that I completed is also uploaded. The soap note MUST be over a child or adolescent between ages 5-17 and cover a mental disorder/ illness. If the writer chose they can revise the soap note 7 and include required information.
Description of assignment:
Subjective Data:
The Chief Complaint is clear, concise, and verbatim from pt. History of Present Illness is thorough yet concise and provides a chronological account of symptoms and contextual factors that are sufficiently descriptive (OLDCARTS) to validate Dx per DSM-5 TR criteria. All pertinent negatives are included. A longitudinal course of illness is clear. Current psychiatric medications and responses are included.
Objective Data:
MSE contains the required elements. It is in narrative form and effectively and vividly describes the patient’s presentation. Concrete examples of all assessment results are included i.e. “able to correctly interpret 2/3 simple proverbs” to validate documentation of “abstract thought intact.”
Assessment:
The differential is pertinent to signs and symptoms, the formulation contains evidence of critical thought and subject knowledge, and reasonable diagnoses are made per DSM-5. Clearly met criteria for diagnoses tendered are explicit in the HPI (History of Present Illness) description and substantiated with the MSE.
Plan:
An evidence-based treatment plan is presented with detailed rationales. The level of detail reflects the student’s ability to choose treatments based not only on FDA approval or current evidence but also on the nuances and unique characteristics of each. The treatment plan is holistic and comprehensive. There is compelling evidence of the student’s synthesis of information and critical thought. Includes neurobiology information on the disorder.
