Assignment 2: Focused SOAP Note and Patient Case Presentation

College students searching for clear guidance on completing a focused psychiatric SOAP note and presenting a professional clinical case study will find this assignment framework helpful for developing real-world mental health documentation and assessment skills.

Instructions

Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. You may find that documenting these encounters enriches your clinical growth as you begin noticing patterns in patient care. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care. It often becomes easier over time to see how structured documentation strengthens clinical decision making.

For this Assignment, you will document information about a patient that you examined during the last 4 weeks, using the Focused SOAP Note Template provided. You may discover that taking time to organize your thoughts before writing improves the clarity of your final submission. You will then use this note to develop and record a case presentation for this patient. Recording your presentation can also help you develop confidence in articulating clinical reasoning.

To Prepare

Review the Kaltura Media Uploader resource for help creating your self-recorded Kaltura video so you feel comfortable navigating the platform when it is time to submit. Increasing familiarity with your recording tools often reduces stress before presenting.

• Select an adult patient that you examined during the last 4 weeks who presented with a disorder other than the disorder present in your Week 3 Case Presentation. You might find that comparing different disorders from each week highlights your growing diagnostic abilities.
• Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. A consistent structure can support you in capturing essential information accurately. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations. Please Note:
• All SOAP notes must be signed, and each page must be initialed by your Preceptor. Ensuring these signatures are complete helps maintain the integrity of your practicum documentation. Note: Electronic signatures are not accepted.
• When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor. Keeping both versions organized will make submission smoother for you.
• You must submit your SOAP note using SafeAssign. Submitting both files on time helps you avoid deduction of points. Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.
• Then, based on your SOAP note of this patient, develop a video case study presentation. Practicing your delivery beforehand can help ensure that your presentation fits within the time limit. Take time to practice your presentation before you record.
• Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning. Integrating current research makes your case study stronger and more evidence based.
• Ensure that you have the appropriate lighting and equipment to record the presentation. Good technical quality will help your audience stay focused on your clinical analysis.

The Assignment

Record yourself presenting the complex case study for your clinical patient. Preparing in advance can help you feel more confident when discussing the patient’s history and symptoms. In your presentation:

• Dress professionally and present yourself in a professional manner. Maintaining this standard reinforces your role as a developing clinician.
• Display your photo ID at the start of the video when you introduce yourself. This simple step supports verification for practicum requirements.
• Ensure that you do not include any information that violates the principles of HIPAA. Removing identifiable details also ensures the patient’s privacy and safety. (i.e., don’t use the patient’s name or any other identifying information).
• Present the full complex case study. Sharing a detailed overview helps your audience follow your diagnostic thinking. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
• Report normal diagnostic results as the name of the test and “normal” (rather than specific value). This method simplifies results while still maintaining accuracy. Abnormal results should be reported as a specific value.
• Be succinct in your presentation, and do not exceed 8 minutes. Staying within the time limit helps you prioritize key clinical elements. Specifically address the following for the patient, using your SOAP note as a guide:

Subjective

What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? You may start noticing how patient narratives guide your diagnostic reasoning. What is the duration and severity of their symptoms? Reflecting on time patterns can often reveal emerging diagnostic clues. How are their symptoms impacting their functioning in life?

Objective

What observations did you make during the psychiatric assessment? Your ability to recognize subtle behavioral cues may improve as you conduct more assessments.

Assessment

Discuss patient mental status examination results. Careful interpretation will help you align symptoms with diagnostic criteria. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms. This part of your assignment often reveals your growing clinical reasoning skills.

Plan

What was your plan for psychotherapy? You may observe how different therapy styles complement your overall treatment approach. What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Be sure to include at least one health promotion activity and one patient education strategy.

Reflection Notes

What would you do differently with this patient if you could conduct the session over? Reflecting on professional growth can enhance your future sessions. If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be. Many students find that reflection deepens their understanding of therapeutic relationships.

Adding supportive insights at the end of your assignment can help reinforce your knowledge of clinical documentation expectations and showcase your developing competency in psychiatric practice. Highlighting the value of structured reflection can also demonstrate commitment to continual improvement.

 References

1. American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). APA Publishing.
2. Shen, Y., Zhang, L., & Mendenhall, A. N. (2021). Improving diagnostic accuracy in psychiatric assessment: A systematic review. Journal of Clinical Psychiatry, 82(4), 21r14052.
3. Wang, Q., Beard, C., & Björgvinsson, T. (2020). Psychotherapy outcomes in adult psychiatric settings: A large-scale evaluation. Psychological Services, 17(3), 283–294.
4. Hilty, D. M., Torous, J., Chan, S. R., & Yellowlees, P. M. (2019). Evidence-based models for clinical assessment via telepsychiatry. Psychiatric Clinics of North America, 42(4), 563–575.
5. McLaughlin, K. A., & Hatzenbuehler, M. L. (2023). Advances in adult mental health treatment planning: Integrating evidence-based modalities. Annual Review of Clinical Psychology, 19, 421–445.