Mental Health SOAP Note Research Paper
Order ID |
53563633773 |
Type |
Essay |
Writer Level |
Masters |
Style |
APA |
Sources/References |
4 |
Perfect Number of Pages to Order |
5-10 Pages |
Description/Paper Instructions
Mental Health SOAP Note Research Paper
Mental, Health, SOAP, Note, Research, Paper
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Subjective
Ms. Tina Jones is a 28yo pleasant AA female. She is alert, well- groomed. Speech is fluent and words are clear. Thought process are coherent, insight is good. She maintains eye contact during our interview. She presents to the clinic c/o difficult sleeping this past month, and is occurring more often this past 3 1/2 weeks. She reports feeling “nervous, excessive working before bedtime” She feels “on edge” due to lack of sleep. She sleeps an average of 4-5 hours, and is awake by 8am.
She sleeps like a “log” when she has fallen asleep. She watches tv and reads book to assist with her sleep. She does not take naps. She drinks four diet coke daily, last intake at 4pm. Social Hx: stress in her life, due to upcoming exams and job search after graduation. She has support from her family, friends and her church members whom she sees twice a week. Father passed away, felt sad, and is coping well.
No counseling, but felt she did not need one for her grieving process. Drug use: hx of the use at 20 years old: stopped. No tobacco use. ETOH: socially. She does not exercise, for she gets tired with work and school. No medications used for insomnia. ROS: Loss of appetite, probably due to her feeling tired. Has increase fatigue in the daytime.
Has changes in concentration due to fatigue. PMHX: Diabetes: no meds Asthma: on albuterol and Proventil: controlled asthma Mental health: denies depression, suicidal thoughts or homicidal ideation. no hx of anxiety except for today due to upcoming exams and future job search. Does feel her mood has been “off” and does not feel like herself. She denies tension or memory loss. Family hx: No mental illness, only Uncle with alcoholism.
HPI: Ms. Jones presents to the clinic complaining of difficulty sleeping which she notes to have started 1 month ago. She states that her sleep is “shallow and not restful”. She complains of difficult falling asleep at least 4 or 5 nights per week, but states that she able to stay asleep without difficulty. On average she sleeps 4 or hours per night and awakens at 8:00am daily. She states that she has a fairly consistent schedule on weekdays and weekends.
She does not take any prescription or over the counter sleep aids. She limits screen time prior to bed and does not ingest caffeine after 4pm daily. She endorses decreased feelings of sleepiness over t past month. She denies difficulties awaking, but does not feel res in the morning and has daytime fatigue (rates 5/10 severity), restlessness, and irritability (rates 2/10 severity). She does not ta naps.
Social History: She states that she has some stress related to the upcoming examinations and her impending job search upon graduation. She states that she has a strong support system ma up of friends and family and she is active in her church. She state that she copes with stress by staying organized. She enjoys read and watching television (1-2 hours per day).
She states that her father died in a car accident a year and a half ago, which was difficult for her and she experienced some difficulties with sleep that time as well. She denies use of tobacco. She drinks approximately 10-12 alcoholic beverages per month, but never m than 3 per sitting and does not note any impact on her sleep.
Sh has used marijuana in the past, but no current use and denies ot illicit drugs. She does not exercise regularly, but states that her jo somewhat active and she walks 5-15 minutes daily. She drinks 1 diet colas per day. Family History: Denies any history of known sleep disorders or psychiatric disorders.
Review of Systems: • General: Denies changes in weight, weakness, fever, chills, and night sweats. Does complain of increasing daytime fatigue. • Neurologic: Denies loss of sensation, numbness, tingling, tremo weakness, paralysis, fainting, blackouts, or seizures. Endorses changes in concentration and sleep.
Denies changes or difficulties coordination. • Psychiatric: States that her mood has been “off” and she does feel like herself. She does complain of increased anxiety related t upcoming exams and job search. She has no history of depression but does state that she feels helpless and notes that her performance at work and school is beginning to decline. She den tension or memory loss. No past suicide attempts. Denies suicide homicidal ideation.
Assessment
Insomnia related to anxiety Sleep disturbance related to anxiety
Plan
Encourage a diary of her episodes of insomnia and anxiety: stating associated factors and what helps with the anxiety Offer cognitive behavioral therapy (CBT) Educate on anxiety reduction strategies including deep breathing, relaxation and guided imagery.
Offer consultation to behavioral Health Specialist Encourage diet and exercise regimen Decrease caffeine intake Offer telephone appointment to check in with her in a week Give warning signs on when to seek for help, as in inability to care for self, depression, anxiety or suicidal thoughts.
- Encourage Ms. Jones to continue to monitor symptoms and log episodes of insomnia and anxiety with associated factors and br log to next visit. • Encourage to decrease caffeine consumption and increase inta of water and other fluids. • Educate on anxiety reduction strategies including deep breathing relaxation, and guided imagery. Continue to monitor and explore need for possible referral to social work/psychiatry or pharmacal intervention.
Discuss need to maintain regular sleep and wake schedule and sleep hygiene techniques including limiting caffeine after 2pm, limiting fluids after dinner, limiting screen time or stimulating activities after 8pm, and to get out of bed if awaken in the middle the night.
Educate to limit alcohol and depressant medications (including diphenhydramine and Tylenol PM). • Educate on when to seek further or emergent care including feelings of self-harm or hopelessness. • Revisit clinic in 2-4 weeks for follow up and evaluation.
RUBRIC
QUALITY OF RESPONSE |
NO RESPONSE |
POOR / UNSATISFACTORY |
SATISFACTORY |
GOOD |
EXCELLENT |
Content (worth a maximum of 50% of the total points) |
Zero points: Student failed to submit the final paper. |
20 points out of 50: The essay illustrates poor understanding of the relevant material by failing to address or incorrectly addressing the relevant content; failing to identify or inaccurately explaining/defining key concepts/ideas; ignoring or incorrectly explaining key points/claims and the reasoning behind them; and/or incorrectly or inappropriately using terminology; and elements of the response are lacking. |
30 points out of 50: The essay illustrates a rudimentary understanding of the relevant material by mentioning but not full explaining the relevant content; identifying some of the key concepts/ideas though failing to fully or accurately explain many of them; using terminology, though sometimes inaccurately or inappropriately; and/or incorporating some key claims/points but failing to explain the reasoning behind them or doing so inaccurately. Elements of the required response may also be lacking. |
40 points out of 50: The essay illustrates solid understanding of the relevant material by correctly addressing most of the relevant content; identifying and explaining most of the key concepts/ideas; using correct terminology; explaining the reasoning behind most of the key points/claims; and/or where necessary or useful, substantiating some points with accurate examples. The answer is complete. |
50 points: The essay illustrates exemplary understanding of the relevant material by thoroughly and correctly addressing the relevant content; identifying and explaining all of the key concepts/ideas; using correct terminology explaining the reasoning behind key points/claims and substantiating, as necessary/useful, points with several accurate and illuminating examples. No aspects of the required answer are missing. |
Use of Sources (worth a maximum of 20% of the total points). |
Zero points: Student failed to include citations and/or references. Or the student failed to submit a final paper. |
5 out 20 points: Sources are seldom cited to support statements and/or format of citations are not recognizable as APA 6th Edition format. There are major errors in the formation of the references and citations. And/or there is a major reliance on highly questionable. The Student fails to provide an adequate synthesis of research collected for the paper. |
10 out 20 points: References to scholarly sources are occasionally given; many statements seem unsubstantiated. Frequent errors in APA 6th Edition format, leaving the reader confused about the source of the information. There are significant errors of the formation in the references and citations. And/or there is a significant use of highly questionable sources. |
15 out 20 points: Credible Scholarly sources are used effectively support claims and are, for the most part, clear and fairly represented. APA 6th Edition is used with only a few minor errors. There are minor errors in reference and/or citations. And/or there is some use of questionable sources. |
20 points: Credible scholarly sources are used to give compelling evidence to support claims and are clearly and fairly represented. APA 6th Edition format is used accurately and consistently. The student uses above the maximum required references in the development of the assignment. |
Grammar (worth maximum of 20% of total points) |
Zero points: Student failed to submit the final paper. |
5 points out of 20: The paper does not communicate ideas/points clearly due to inappropriate use of terminology and vague language; thoughts and sentences are disjointed or incomprehensible; organization lacking; and/or numerous grammatical, spelling/punctuation errors |
10 points out 20: The paper is often unclear and difficult to follow due to some inappropriate terminology and/or vague language; ideas may be fragmented, wandering and/or repetitive; poor organization; and/or some grammatical, spelling, punctuation errors |
15 points out of 20: The paper is mostly clear as a result of appropriate use of terminology and minimal vagueness; no tangents and no repetition; fairly good organization; almost perfect grammar, spelling, punctuation, and word usage. |
20 points: The paper is clear, concise, and a pleasure to read as a result of appropriate and precise use of terminology; total coherence of thoughts and presentation and logical organization; and the essay is error free. |
Structure of the Paper (worth 10% of total points) |
Zero points: Student failed to submit the final paper. |
3 points out of 10: Student needs to develop better formatting skills. The paper omits significant structural elements required for and APA 6th edition paper. Formatting of the paper has major flaws. The paper does not conform to APA 6th edition requirements whatsoever. |
5 points out of 10: Appearance of final paper demonstrates the student’s limited ability to format the paper. There are significant errors in formatting and/or the total omission of major components of an APA 6th edition paper. They can include the omission of the cover page, abstract, and page numbers. Additionally the page has major formatting issues with spacing or paragraph formation. Font size might not conform to size requirements. The student also significantly writes too large or too short of and paper |
7 points out of 10: Research paper presents an above-average use of formatting skills. The paper has slight errors within the paper. This can include small errors or omissions with the cover page, abstract, page number, and headers. There could be also slight formatting issues with the document spacing or the font Additionally the paper might slightly exceed or undershoot the specific number of required written pages for the assignment. |
10 points: Student provides a high-caliber, formatted paper. This includes an APA 6th edition cover page, abstract, page number, headers and is double spaced in 12’ Times Roman Font. Additionally, the paper conforms to the specific number of required written pages and neither goes over or under the specified length of the paper. |
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