Answer DQ Questions.

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wnzrf23

Humanities

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Topic 6 DQ 1 In Topic 5, you created a treatment plan for your client. Create a SOAP note that would go in the client’s chart following the visit. Post the SOAP note as a reply to this discussion thread. For follow-up discussion, evaluate at least two of your peers' SOAP notes. Would you have documented anything differently? Why or why not?

Topic 6 DQ 2 In Topic 5, you created a treatment plan for your client. If your client was to attend a group therapy session, write a progress note for that client’s participation in that group. How is writing a group progress note different than an individual progress note?

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Treatment Plan Based on the information collected in Week 4, complete the following treatment plan for your client Eliza. Be sure to include a description of the problem, goals, objectives, and interventions. Remember to incorporate the client's strengths and support system in the treatment plan. Client: ____Eliza________________________________________ Date: ______________ Age: ______ DOB: __________________ DSM Diagnosis ICD Diagnosis Depression Mild depressive disorder Goals / Objectives: □ Mood Stabilization Interventions: □ Psychotropic Medication Referral & Consultation □ Journaling □ Cognitive Behavior Therapy □ Skill Training □ Emotion Recognition – Regulation Techniques Frequency: □ Weekly □ Bi Weekly □ Monthly □ other: ____________________ □ Group □ Individual □ Family □ Anxiety Reduction □ Psychotropic Medication Referral & □ Weekly Consultation □ Bi Weekly □ Journaling □ Monthly □ Cognitive Behavior Therapy □ other: □ Skill Training ____________________ □ Relaxation Techniques □ Group □ Individual □ Family □ Reduce Obsessive Compulsive □ Psychotropic Medication Referral & □ Weekly Behaviors Consultation □ Bi Weekly □ Journaling □ Monthly □ Cognitive Behavior Therapy □ other: □ Skill Training ____________________ □ Group □ Individual □ Family □ Decrease Sensitivity to □ Verbalize Memories Triggers □ Weekly Trauma Experiences &Emotion □ Bi Weekly □ Desensitize Trauma Triggers and □ Monthly Memories □ other: □ Utilize Healing Model/Support ____________________ (Mending the Soul) □ Group □ Individual □ Family © 2017. Grand Canyon University. All Rights Reserved. □ Establish and Maintain Eating Disorder Recovery □ Maintain Abstinence from substances (Alcohol/Drugs) □ Increase Coping Skills □ Stabilize, Adjustment to New Life Circumstances □ Decrease/Eliminate Self Harmful Behaviors □ Improve Relationships □ Overcome Denial □ Identify Negative Consequences □ Menu Planning □ Nutrition Counseling □ Body Image Work □ Healthy Exercise □ Trigger Mgmt. Recovery Plan □ CBT □ Substance Use Assessment □ Stepwork □ Overcome Denial □ Identify Negative Consequences □ Commitment to Recovery Program □ Attend Meetings □ Obtain Sponsor □ Weekly □ Bi Weekly □ Monthly □ other: ____________________ □ Group □ Individual □ Family □ Weekly □ Bi Weekly □ Monthly □ other: ____________________ □ Group □ Individual □ Family □ DBT Skills Training □ Weekly □ Problem Solving Techniques □ Bi Weekly □ Emotion Recognition & Regulation □ Monthly □ Communication Skills □ other: ____________________ □ Group □ Individual □ Family □ Alleviate Distress □ Weekly □ Cognitive Behavior Therapy □ Bi Weekly □ Stress Management □ Monthly □ Skills Training □ other: □ Improve Daily Functioning ____________________ □ Develop Healthy Support □ Group □ Individual □ Family □ Cognitive Behavior Therapy □ Weekly □ Skills Training □ Bi Weekly □ Develop and Utilize Support System □ Monthly □ other: ____________________ □ Group □ Individual □ Family □ Communication Skills □ Weekly □ Active Listening □ Bi Weekly □ Family Therapy □ Monthly © 2017. Grand Canyon University. All Rights Reserved. □ Assertiveness □ Setting Healthy Boundaries □ Improve Self Worth □ Affirmation Work □ Positive Self Talk □ Skills Training □ Confidence Building Tasks □ Grief Reduction and Healing from Loss □ Psychoeducation on Grief Process/ Stages □ Process Feeling □ Emotion Regulation Techniques □ Reading/Writing Assignments □ Develop/Utilize Support □ Develop Anger Management Skills □ Decrease Anger Outbursts □ Emotion Regulation Techniques □ Cognitive Behavior Therapy □ Increase Awareness/Self Control □ other: ____________________ □ Group □ Individual □ Family □ Weekly □ Bi Weekly □ Monthly □ other: ____________________ □ Group □ Individual □ Family □ Weekly □ Bi Weekly □ Monthly □ other: ____________________ □ Group □ Individual □ Family □ Weekly □ Bi Weekly □ Monthly □ other: __________________ □ Group □ Individual □ Family © 2017. Grand Canyon University. All Rights Reserved.
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Explanation & Answer

Attached.

Running Head: SOAP NOTE

1

SOAP Note
Name
Course
Tutor
Date

SOAP NOTE

2

SUBJECTIVE
The patient is a 32 year old female. The female was brought into the hospital by her husband and
close friend. The husband and close friend revealed that the patient has been having restless
nights leading to insomnia, she has been slow in activity, she has also been suicidal and she has
been experiencing loss of appetite which has eventually led to weight loss. As reported by the
husband and friend, the symptoms have become worse in the last two and a half months, and it
has been difficult getting the patient to the doctor. The patient can be seen to be in a state of
distraction, with little to no interaction while she looks sad and disturbed.
OBJECTIVE
Following the test, the patient shows little interest in engaging in activities. The patient has
difficulty sleeping following tests conducted on her sleeping patterns. She also experiences a lot
of restlessness. The patient lacks an appetite, given the decline to eat jelly given in the hospital
and have some water. She gets easily agitated and irritated when asked personal questions, which
gets difficult since the questions are guidance to detecting the main issue. The eyes have dark
rings around them and eye bags too, can be seen. The vital signs of the patient are stable
according to t...


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