Focused SOAP Note
please see attached
please see attached
A 32-year-old patient diagnosed with Obsessive-Compulsive Disorder (OCD) and Bipolar Disorder presents with recurring intrusive thoughts related to cleanliness and compulsive hand-washing. They report periods of heightened energy and impulsivity alternating with depressive episodes. Current treatment includes mood stabilizers lithium and exposure-response prevention therapy for OCD.
There are two (2) questions for this discussion. Please choose one of the questions for your initial posting.
You are required to respond to at least one of your peers. You must respond to a different discussion question than the one you have answered.
You are also required to include a word count in parentheses (your question response must be between 300-500 words), excluding the original question and references. This word count is part of the Discussion Board Rubric.
Please note that there are two dates listed on the Course Schedule. The first is the due date for the initial posting and the second the completion date for the threaded response.
The due date listed here is for full completion of the module, including the threaded discussion. The DB be monitored to verify that the initial posting was completed on the date listed on the schedule.
Directions: Read over the SOAP note and formulate a primary diagnosis. Based on the diagnosis complete the SOAP note with the details that would be expected for the diagnosis. Use UptoDate and/or Dyna MedPlus to find out what is expected from the history and physical, diagnostic workup and management for the diagnosis. Include other peer review resources and and journal articles to support the development of your SOAP note. Complete and attach the evaluation & management score sheet to show how you coded the note for billing in each section.
