ANSWER
Using the given form and specifications, the following organized framework will assist you in creating your Unit 6 Clinical SOAP Note on Major Depressive Disorder:
Title Page (formatted in APA 7th edition)
Description: “Clinical SOAP Note: Major Depressive Disorder”
Name of Student, Name of Course, Number, Date of Institution
Subjective Chief Complaint (CC) for the SOAP Note Template:
The main issue or grievance of the patient expressed in their own words, such as “I feel depressed and can’t focus on anything.”
Present Illness History (HPI):
A thorough explanation of the depression symptoms, including their onset, duration, frequency, and triggers.
Examples include depression, disinterest, exhaustion, changes in food, irregular sleep patterns, or a sense of inadequacy.
Psychiatric Background:
history of depression or other mental health issues, including previous diagnoses, hospital stays, therapy, or prescription use.
Health History:
allergies, ongoing prescription drugs, previous surgeries, and chronic illnesses.
Family Background:
Family members with a history of anxiety, depression, or other mental illnesses.
History of Society:
Work, housing, substance usage, relationships, and support networks are examples of lifestyle factors.
System Review (ROS):
Pay attention to constitutional and neuropsychiatric symptoms (e.g., headaches, changes in weight, and fatigue).
Mental Status Examination (MSE) objective:
Appearance: Explain the patient’s clothing and personal hygiene.
Conduct: cooperative, reticent, or restless.
Voice: Volume, tone, and rate.
Mood/effect: The observable effect and the patient’s stated mood.
Content/Thought Process: Reasonable, purposeful, or indicative of rumination.
Cognitive: Vigilance, recall, and focus.
Judgement/Insight: The capacity to comprehend situations and reach conclusions.
Vital Signs:
If necessary, note vital statistics (blood pressure, heart rate).
If a physical examination is performed:
Make a note of any pertinent discoveries, particularly about the nervous system.
Evaluation Primary Diagnosis:
Refer to the DSM-5 diagnostic criteria for Major Depressive Disorder (MDD), indicating the severity (mild, moderate, severe).
Provide clinical data to back up this diagnosis.
Differential Diagnosis:
Persistent depression, or dysthymia.
Bipolar disorder (phase of depression).
depression-related symptoms of generalized anxiety disorder.
Arrange for psychotherapy:
suggested frequency and type of therapy (e.g., CBT, IPT).
Interventions Using Pharmacology:
Suggested drugs (e.g., SNRIs, SSRIs). Add the dosage, possible adverse effects, and the justification for your decision.
Interventions Without Drugs:
Lifestyle modifications include food, exercise, and sleep hygiene.
Patient Instruction:
Describe MDD, the objectives of treatment, and the significance of taking medications as prescribed.
Provide resources for support groups and deal with stigma.
Follow-up:
Follow-up appointment schedule (e.g., two weeks to evaluate medication efficacy).
Suggestions:
therapist for psychotherapy or a psychiatrist (if required for complicated conditions).
Citations
DSM-5: Used to establish diagnostic standards.
The course textbook serves as a resource for evidence-based care.
Peer-Reviewed Article: Current research on treating MDD.
Other Academic Support for pharmaceutical treatments or psychotherapy techniques is the source.
I can assist you draft some parts of the SOAP note or edit your submission for clarity and APA formatting if you’d like!
QUESTION
Unit 6-Clinical SOAP Note on Major depressive Disorder. Due 10-9-24. 800w and 4 references. Please use course resource/ textbook and DSM5 as reference. Must Use attached template
Instructions
Every other week students will choose one patient encounter to submit a Follow-up SOAP note for review.
Follow the rubric to develop your SOAP notes for this term.
The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.
All work should be original and submitted as a Word document unless otherwise indicated in the assignment instructions. ALL assignments need to be APA 7 format and accompanied title page in APA 7th edition format in order that the work would be properly identified for the student, the course, and the assignment. Work submitted without a title page will receive a grade of 0.
Complete this assignment and submit it to this assignment dropbox by Sunday at 11:59 pm CT.