List 8 PROGRESS NOTES in SOAP format of the . Describe the activities you completed during this time period with patients. NOTE: ( The progress notes has to be related with what the Psychiatric Mental Health Nurse Practitioner do with Child and adolescents with different psychiatric conditions). 8 different notes with different patients scenarios.
SOAP Progress Notes for Child and Adolescent Patients with Psychiatric Conditions
As a Psychiatric Mental Health Nurse Practitioner (PMHNP) specializing in child and adolescent mental health, I have encountered a range of psychiatric conditions in my practice. Here, I will provide eight progress notes in the SOAP format to describe the activities I completed during a specific time period with these patients. These progress notes aim to highlight the interventions and assessment findings relevant to each case scenario.
Note 1:
Subjective:
The patient, a 10-year-old male, presented with symptoms of attention-deficit/hyperactivity disorder (ADHD). His mother reported difficulties with impulsivity, hyperactivity, and poor academic performance. The patient has been experiencing these symptoms for the past year.
Objective:
On assessment, the patient displayed fidgeting, difficulty staying seated, and interrupted conversations. He scored high on the Conners’ ADHD Rating Scale, indicating the presence of ADHD symptoms. The patient’s school records also confirmed academic struggles.
Assessment:
Based on the assessment findings, the patient’s symptoms align with a diagnosis of ADHD. The impact of these symptoms on his academic performance and daily functioning must be addressed.
Plan:
I will discuss treatment options, including medication and behavior therapy, with the patient’s mother. Psychoeducation regarding ADHD, behavior management strategies, and academic accommodations will be provided. Referral to a specialized psychologist for comprehensive testing and intervention planning may also be considered.
Note 2:
Subjective:
A 15-year-old female was referred to me for evaluation and treatment of depression. The patient reported feelings of sadness, low motivation, decreased energy levels, hypersomnia, and difficulty concentrating. She stated that these symptoms had been present for the past six months.
Objective:
On assessment, the patient exhibited a flat affect, poor eye contact, low energy levels, and psychomotor retardation. She scored high on the Patient Health Questionnaire-9 (PHQ-9), indicating a moderate level of depression.
Assessment:
Based on the assessment findings and the patient’s self-report, she meets criteria for major depressive disorder (MDD). The severity of symptoms suggests the need for intervention to prevent further deterioration of her mental health.
Plan:
I will initiate psychotherapy sessions with the patient to explore the underlying psychological factors contributing to her depression. In collaboration with the patient, her family, and other healthcare providers, I will develop a treatment plan that may include a combination of psychotherapy, pharmacotherapy, and lifestyle modifications.
Note 3:
Subjective:
A 12-year-old male with a history of anxiety presented with complaints of excessive worry, restlessness, and difficulty sleeping. The patient’s mother reported that these symptoms have intensified in the past two months and are affecting the patient’s school performance.
Objective:
On assessment, the patient demonstrated somatic complaints, such as headaches and stomachaches, as well as excessive hand wringing. He scored high on the Screen for Child Anxiety Related Disorders (SCARED) scale, indicating the presence of anxiety symptoms.
Assessment:
The patient’s symptoms are consistent with a diagnosis of generalized anxiety disorder (GAD). The increased severity and impact of anxiety on the patient’s daily functioning indicate the need for intervention and support.
Plan:
I will discuss cognitive-behavioral therapy (CBT) techniques with the patient and his family to address anxiety symptoms. Relaxation exercises, mindful practices, and exposure-based techniques will be incorporated into the treatment plan. Regular follow-up sessions will allow for the monitoring of progress and adjustments as needed.
Note 4:
Subjective:
A 14-year-old female was brought by her parents to seek help for self-harm behaviors. The patient reported feelings of emptiness, a history of suicidal ideation, and frequent self-cutting episodes. Her parents expressed concern about her safety.
Objective:
On assessment, the patient exhibited fresh self-inflicted wounds on her arms and legs. She showed emotional distress and displayed poor impulse control. The patient’s Psychosocial Assessment revealed a history of childhood trauma.
Assessment:
Based on the assessment findings, the patient meets criteria for borderline personality disorder (BPD) and deliberate self-harm. Her self-harm behaviors indicate the need for immediate intervention to ensure her safety.
Plan:
I will prioritize the patient’s safety by establishing a safety plan with her and her parents. A referral to a specialized therapist trained in dialectical behavior therapy (DBT) will be made to address the underlying emotional dysregulation and self-harm behaviors. Collaboration with the patient’s family and other healthcare providers will be essential to create a comprehensive treatment plan.
Note 5:
Subjective:
A 16-year-old male presented with symptoms of post-traumatic stress disorder (PTSD) following a car accident. The patient reported recurrent nightmares, intrusive thoughts, and avoidance of driving or being in a vehicle. He confirmed that the car accident occurred six months ago.
Objective:
On assessment, the patient displayed hyperarousal symptoms, such as hypervigilance and exaggerated startle responses. He endorsed flashbacks and panic attacks triggered by reminders of the accident. His Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) score indicated the presence of PTSD symptoms.
Assessment:
The patient’s symptoms are consistent with a diagnosis of PTSD. The persistent nature of these symptoms and their impact on the patient’s daily life necessitates intervention to address trauma-related distress.
Plan:
I will facilitate trauma-focused cognitive-behavioral therapy (TF-CBT) sessions with the patient to process and challenge traumatic memories. Exposure-based techniques, relaxation strategies, and coping skills training will be utilized. Collaboration with the patient’s family and involvement in a support group for trauma survivors may also be beneficial.
Note 6:
Subjective:
A 13-year-old male with a history of oppositional defiant disorder (ODD) and conduct disorder (CD) presented with disruptive behaviors at home and school. The patient’s parents reported frequent arguments, defiance, aggression, and truancy.
Objective:
On assessment, the patient displayed anger outbursts, refused to follow rules or instructions, and engaged in verbal and physical aggression. The patient’s school records indicated multiple suspensions and poor academic performance.
Assessment:
The patient’s behavior pattern aligns with the criteria for ODD and CD. The severe disruptions caused by the patient’s conduct issues warrant intervention to help him develop healthier coping mechanisms and improve his relationships.
Plan:
I will collaborate with the patient, his parents, and school personnel to develop a behavior management plan that includes consistent discipline strategies, clear boundaries, and reinforcement of positive behaviors. Individual therapy sessions to address anger management, impulse control, and problem-solving skills will also be conducted.
Note 7:
Subjective:
A 16-year-old female requested support for symptoms of anorexia nervosa. The patient described restricting food intake, excessive exercise, and dissatisfaction with her body weight. She stated that these behaviors have been present for the past nine months.
Objective:
On assessment, the patient exhibited extreme thinness, a low body mass index (BMI), and excessive exercise habits. Her Eating Disorder Examination-Questionnaire (EDE-Q) scores indicated the presence of anorexia nervosa symptoms.
Assessment:
The patient’s symptoms meet criteria for anorexia nervosa, which requires immediate intervention to address the associated health risks and psychological distress.
Plan:
I will initiate an evidence-based approach, such as family-based therapy (FBT), to involve the patient’s family in refeeding and addressing the underlying familial dynamics. Psychoeducation about the medical consequences of anorexia nervosa and the importance of nutritional rehabilitation will be crucial. Regular monitoring of weight, nutritional status, and psychological well-being will guide the treatment plan.
Note 8:
Subjective:
A 14-year-old male with a history of autism spectrum disorder (ASD) presented with difficulties in social interaction, communication, and restricted interests. The patient’s parents expressed concern about his academic performance and limited peer relationships.
Objective:
On assessment, the patient displayed inflexible thinking patterns, repetitive behaviors, difficulty with social reciprocity, and limited eye contact. He scored high on the Social Responsiveness Scale-2 (SRS-2), indicating the presence of autism-related symptoms.
Assessment:
The patient’s symptoms align with a diagnosis of ASD. The functional impairments caused by his autistic traits and their impact on his development warrant intervention to improve his adaptive functioning.
Plan:
I will collaborate with the patient’s parents and school professionals to develop an individualized education plan (IEP) that addresses his specific learning needs and social communication challenges. Applied behavior analysis (ABA) techniques, social skills training, and speech therapy will also be incorporated into the treatment plan. Regular progress monitoring and adjustment of interventions will be essential to support the patient’s development.
In conclusion, as a PMHNP specializing in child and adolescent mental health, my activities during this time period with patients involved performing assessments, making diagnoses, and developing treatment plans for a range of psychiatric conditions. These progress notes demonstrate the utilization of evidence-based interventions to address the unique needs and challenges presented by each patient. Continuing care, collaboration with families, and regular follow-up sessions will be crucial to support their ongoing mental health and well-being.