As a Psychiatric Mental Health Nurse Practitioner (PMHNP) working with children and adolescents with various psychiatric conditions, it is crucial to maintain accurate and comprehensive progress notes. Progress notes are essential documents that provide a detailed account of the activities and interventions conducted during a specific time period with patients. These notes not only serve as a record-keeping tool but also facilitate communication and collaboration among healthcare professionals involved in the patient’s care. In this assignment, I will provide an example of eight progress notes in a SOAP format, focusing on different patient scenarios.
1. Progress Note for Patient A – Major Depressive Disorder
During the session, Patient A, a 15-year-old with a diagnosis of major depressive disorder, reported feeling persistently sad and experiencing a loss of interest in previously enjoyed activities. Patient denies any suicidal ideation or intent. Patient’s mother shared concerns about their child’s withdrawal from family and friends. Patient reported poor appetite and difficulty sleeping.
Patient’s affect appeared depressed, exhibiting minimal eye contact and slouched posture. The patient’s mother reports that the patient’s school grades have declined recently. Mental status examination revealed a depressed mood, psychomotor slowing, and low self-esteem.
Based on the symptoms reported and observed, Patient A continues to exhibit signs of major depression. Differential diagnosis includes adjustment disorder with depressed mood, depressive disorder due to a medical condition, and bipolar disorder.
To address Patient A’s major depressive disorder, I will initiate a treatment plan that includes individual therapy sessions focusing on cognitive-behavioral therapy (CBT) to identify negative thought patterns and promote positive coping skills. Additionally, I will educate the patient and their family on the risks and benefits of pharmacotherapy options such as selective serotonin reuptake inhibitors (SSRIs) and closely monitor for any adverse effects.
2. Progress Note for Patient B – Attention-Deficit Hyperactivity Disorder (ADHD)
Patient B, an 8-year-old diagnosed with attention-deficit hyperactivity disorder (ADHD), presented with increased impulsivity, difficulty staying focused, and disruptive behaviors. Patient’s parents reported concerns about academic performance, school suspensions, and strained peer relationships.
Patient exhibited hyperactivity, restlessness, and difficulty following instructions. The teacher provided additional information, reporting frequent classroom disruptions due to impulsive outbursts and difficulty completing tasks. Mental status examination revealed a distractible affect and fidgeting.
Based on the symptoms reported by the family and teacher, Patient B’s presentation is consistent with ADHD. Rule out other possible comorbid conditions such as oppositional defiant disorder (ODD) or conduct disorder (CD).
To manage Patient B’s ADHD symptoms, I will initiate a multimodal approach. This will include parent training to enhance behavioral management techniques, school consultation to develop an individualized education plan (IEP) with appropriate classroom accommodations, and consideration of stimulant medication if symptoms persist or significantly impair functioning. Regular follow-up appointments will be scheduled to monitor treatment response and adjust the treatment plan as necessary.
3. Progress Note for Patient C – Autism Spectrum Disorder (ASD)
Patient C, a 10-year-old diagnosed with autism spectrum disorder (ASD), attended the session accompanied by their parents. Parents expressed concerns over their child’s difficulty with social interactions and communication. Patient’s mother mentioned that the child has been avoiding eye contact and has heightened sensitivities to sensory stimuli.
During the session, Patient C demonstrated limited verbal communication and relied heavily on nonverbal gestures. The patient exhibited repetitive movements and a fixed interest in certain objects. Mental status examination revealed impaired social interaction, rigidity in behavior, and restricted interests.
Patient C’s symptoms align with the diagnostic criteria for autism spectrum disorder. Rule out other possible neurodevelopmental disorders such as intellectual disability.
To support Patient C’s needs, an individualized treatment plan incorporating applied behavior analysis (ABA) techniques will be implemented. This will involve teaching social skills, addressing sensory sensitivities, and developing a visual schedule to promote predictability and reduce anxiety. Collaboration with the school will be initiated to ensure consistency across environments and support the child’s educational needs.