SOAP Note:
CC: 36 year old Caucasian female presents to your clinic with suicidal thoughts. She also has history of seizures. She is currently sexually active and not using any birth control method. Her LMP was 3 weeks ago and has multiple partners.
Medication List:
Celexa 40 mg one tab by mouth daily.
Wellbutrin XL 300 mg one tab by mouth daily.
A. Write a SOAP note of a hypothetical case of a patient that presents to your clinic with suicidal ideation including data listed above. Please include all the components of SOAP note.
B. Document detailed Mental Health and Neurological PE findings on SOAP note.
After completing SOAP note, please answer following questions below:
1. What history questions are important in this case?
2. What are red flags questions to ask in patient with suicidal ideation?
3. What are key highlights to document in assessment of this patient in objective findings of SOAP note?
4. What are monitoring parameters for Celexa?
5. When is Wellbutrin contraindicated?
6. Are her current medications safe for pregnancy?
7. Is the patient safe to drive? What clearance does she need?
Please review Epocrates and UpToDate for medications review.
Write a substantive response to a minimum of two different students. Is objective and subjective data included in the right format? Please be specific to information related to the SOAP note format.
Is objective and subjective data included in the right format? Please be specific to information related to the SOAP note format.
See attached sample SOAP Note: Sample_ SOAP_ Note
20 points will be deducted for combining subjective and objective information. Please see example below:
ROS:
Example 1.
General: Alert and oriented, denies fatigue and chills.
( subjective and objective information is combined above. ” Alert and oriented” is part of PE general and not ROS.
Example 2.
ROS:
Resp: denies cough, wheezing, lungs sounds CTA bilaterally.
( subjective and objective is combined above;” lungs sounds CTA bilaterally” is part of PE
PE:
Example 1:
PE: Denies fatigue and chills. Alert and oriented.
” Denies fatigue and chills” is part of ROS and not PE.
Example 2:
PE: Bowel sounds present all quadrants. Denies abdominal pain.
” Denies abdominal pain” is part of ROS and not PE
SOAP note
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