Create a Focused SOAP Note on this patient using the template
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 again? 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
As a medical professor, my aim is to design and conduct lectures, evaluate student performance, and provide feedback through examinations and assignments for medical college students. In this particular assignment, students are required to create a Focused SOAP Note on a patient and then develop a video case study presentation based on the note. The video presentation should demonstrate the student’s ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of the assignment will also be evaluated to determine the student’s ability to document the complex case as they would in an electronic medical record. The assignment requires students to dress professionally, present the full complex case study, and provide evidence-based assessment, diagnosis, and treatment planning. Additionally, students are expected to incorporate one social determinant of health and suggest a health promotion activity and patient education consideration for improving health disparities and inequities in the realm of psychiatry and mental health. Lastly, students are asked to reflect on their intervention and suggest any changes or follow-up plans.
Answer to the Content:
For this content, as a medical professor, I will ensure that the assignment aligns with the learning objectives of the course and provides a comprehensive assessment and application of knowledge. The SOAP Note template provided should guide students in documenting the patient’s information accurately and effectively. The video case study presentation should demonstrate the student’s ability to communicate information in a clear and concise manner, while also adhering to patient privacy and HIPAA guidelines.
To support the assessment, diagnosis, and treatment planning, I would recommend students to utilize at least five scholarly resources. These resources should be recent, relevant, and credible, providing evidence-based information on the specific mental health condition and treatment options. The incorporation of DSM-5 diagnostic criteria is essential, along with rationale and supporting research for chosen treatment options.
In terms of the video presentation, students should be reminded to dress professionally and maintain a professional demeanor throughout. The use of appropriate lighting and equipment is crucial to enhance the quality of the recording. Students must strictly adhere to HIPAA guidelines to protect patient confidentiality by omitting any identifying information.
To provide an effective presentation, students should include the following components within the 8-minute time limit:
1. Subjective: Students should emphasize the patient’s chief complaint, symptomatology, duration, severity, and the impact of symptoms on their functioning in life.
2. Objective: Students should highlight their observations during the psychiatric assessment, focusing on relevant information related to the patient’s mental health.
3. Assessment: Students should discuss the results of the mental status examination, provide a minimum of three possible differential diagnoses with a justification for each, and indicate the primary diagnosis based on DSM-5 criteria and symptomatology.
4. Plan: Students should describe their treatment plan using clinical practice guidelines supported by evidence-based research. They should discuss FDA-approved psychopharmacologic agents, alternative treatments, and provide rationale for treatment choices with supporting research. A follow-up plan, including referrals, should also be outlined.
5. Social Determinant of Health: Students should identify one social determinant of health that applies to the case in the realm of psychiatry and mental health according to HealthyPeople 2030. They should also propose one health promotion activity and one patient education consideration to address health disparities and inequities in the realm of psychiatry and mental health.
Additionally, students should reflect on their session and suggest any changes they would make if they were given another opportunity. If possible, they should also discuss the effectiveness of their interventions based on follow-up with the patient. If follow-up was not possible, they should propose their next intervention.
Overall, this assignment is designed to assess students’ ability to apply their theoretical knowledge to a complex case, utilize evidence-based practice, and demonstrate effective communication and presentation skills. It also encourages critical thinking, self-reflection, and consideration of health disparities and social determinants of health in psychiatric and mental health care.