[Solved] NU-646 Week 13 Assignment 2: Session Reflection and SOAP Note

NU-646 Week 13 Assignment 2: Session Reflection and SOAP Note

Instructions

Your reflection should address all of the following questions with a minimum of 500 words. Appropriate spelling, grammar, and punctuation are required. Complete sentences are expected. All writing should be in your own words. Use APA references as needed to support your ideas; there is no requirement on number of references to include. Be sure to use APA format.

  1. Which skills did you use in the session? How?
  2. How did the assigned Corey readings, PowerPoints, handouts, and videos inform your therapy session? Please explain in detail.
  3. What were your strengths in the interview?
  4. What were your weaknesses/areas in need of further development in the interview?
  5. How could you improve your interviewing skills? Are there steps you plan on taking? What are those steps?
  6. Was there any time when you felt stuck or uncertain how to respond? Describe what was happening then. Were there times you felt more confident in your responses with the client? Times you were less confident? How? Does this come through in the session?
  7. How were you impacted by the client… your emotions, thoughts, physical reactions, transference, and countertransference, body language?
  8. What was your overall response to the interview? Did you feel connected to the client? Distracted? Disengaged?
  9. What was the quality of your engagement, your empathy?
  10. If you were to continue seeing this particular client, what future directions would you take? How would you conceptualize the case and what would be some of your treatment goals? How would you pursue these goals?

In relation to your partner:

  1. What were your partner’s strengths in the interview?
  2. What were your partner’s weaknesses/areas in need of further development in the interview?
  3. How could your partner improve his/her interviewing skills?

SOAP Note:

  1. Fill in the SOAP note using the template based on your session visit. This should be a follow-up note, as this session was NOT an initial interview.

SOAP Note:

  1. Create a Session Reflection & SOAP Note based on your session with the client.
  2. Use the attached Therapy Session Reflection & SOAP Note Template (Word) for the assignment.

Please refer to the Grading Rubric for details on how this activity will be graded.

 

SOLUTION

Psychiatry/Psychotherapy follow-up SOAP note TEMPLATE

 

Replace all highlighted sections with your data for the assignment (***insert an APA formatted title page as well)

 

Follow-up Session SOAP Note

Patient Name:  Raymond

MRN: Yolette Pithon

Date of Service:         01-27-2020

Start Time:                 10:00

End Time:                  10:54

Billing Code(s):          90213, 90836

(be sure you include strictly psychotherapy codes or both E&M and add on psychotherapy codes if prescribing provider visit)

Accompanied by:      N/A

CC: first time therapy

HPI: The patient has had a dislike for people in the past.

S-Patient states that he is suffering “unbearable” loneliness.

Crisis Issues: He states that he has not considered suicide but has escalated his alcohol intake. Prior to his wife’s death, he had been sober for 20 years and feels like he is withering away and nearing his death.

Reviewed Allergies: allergic rhnitis

Current Medications:

  • Citalopram 40 mg daily
  • Valsartan 80 mg daily
  • Flomax 0.8 mg at bedtime
  • Finasteride 5 mg daily
  • Lipitor 40 mg at bedtime
  • Omeprazole 20 mg daily
  • Cyanocobalamin 1 mg daily
  • Claritin 10 mg daily
  • Flonase nasal spray two puffs to each nostril daily
  • Gabapentin 300 mg tabs 2 tabs three times daily
  • Tylenol 500 mg one to two four times daily prn
  • Brimonidine tartrate 0.15% ophth 1 drop OU twice daily
  • Cosopt 2%-0.5% 1 drop OU at hs
  • Latanoprost 0.005% 2 drops OU at hs
  • Trazodone 25 mg at hs
  • Calcium carbonate 500 mg 1-2 tabs three times daily

ROS: N/A

O-

Vitals:

  • Supine – 135/76, 69; Sitting – 112/75, 76; Standing – 116/76, 74
  • R 20
  • T 96.8
  • O2 98%
  • Pain 3 on 0-10 scale

BMI: 19

Differential Diagnoses:

  1. The patient could be suffering from avoidant personality disorder that is characterized by emotions of significant social inhibition, rejection, inadequacy, and negative criticism. Raymond could be suffering from this disorder because he dislikes people and hence avoids social spaces. Despite his neighbor having fallen and sought the services of nursing home, this patient prefers to remain isolated alone at home, implying that he has a strong dislike for strangers. Despite having feelings of withering away and nearing death, he still wants to live alone.
  2. Concurrent medical illnesses could result in this patient’s depressive situation. The patient has in the past suffered from hypertension, spinal stenosis, depression, hyperlipidemia, and glaucoma, among other complications. Medically ill individuals tend to become clinically depressed as a psychological response to the prognosis, the incapacity and/or pain caused by the illness and its treatment. However, it is important to appreciate that though happening simultaneously, general medical disorder and depression could as well be unrelated.

3. For Raymond, his depression can clearly be associated with grief that came after the mourning of his wife’s death. Grief has taken over this patient’s life and he is now feeling helpless, ………………………..$15