Description
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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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...