Create a Focused SOAP Note on a patient you saw in Practicum (patient information below) using the template provided. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.
Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
33 yo F presents for initial psychiatric evaluation. Transferred from local hospital after intended overdose on Ambien and Ativan. Pt states she was arguing with her boyfriend and his mother and thought the only way to stop the arguing was to take the pills. Reports she was diagnosed with bipolar in 2020 after miscarriage that caused a really low depressive state. Multiple medication trials including depakote, lamictal, abilify, risperdal. Currently on Wellbutrin and Ambien and Ativan. Reports mother died 6 months ago. Used to see therapist in 2020 but not currently. Denies SI now. Has 3 children that she wants to live for. No family history of psych illness. Social supports include work friends and ex husband. Works at 911 dispatch for 1 year. Works night shift and sleep is poor.
She’s well-groomed, guarded, flat affect. Other information can be made up.
Do not agree with the bipolar disorder. No evidence. Cannot recall manic episode. Depressive state due to stressors in life such as the miscarriage and physically and emotionally abusive husband. No previous suicide attempts.
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