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Soap Note

Soap Note Using the attached treatment plan for your client. Create a SOAP note that would go in the client’s chart following the visit. complete the SOAP note separate from the next section. Then evaluate at least two of your peers’ SOAP notes. Would you have documented anything differently? Why or why not? (These are also attached) Please use this reference with one additional reference Schwitzer, A. M., & Rubin, L. C. (2015). Diagnosis and treatment planning skills: A popular culture casebook approach (2nd ed.). Thousand Oaks, CA: Sage Publications, Inc. Treatment Plan for Roger Lelia Denise McKay Grand Canyon University: PCN 610 September 27, 2015 Treatment Plan for Roger Mr. Roger is a patient with paralysis. From his story, three critical issues can be observed. One, he is depressed. Two, he is nursing partial paralysis, and third he takes alcohol. This paper will explain the procedures that Roger will go through for him to be cured. DSM-5 diagnosis The diagnosis of Mr. Roger K. is carried out at two levels because he has disorders related to alcohol use, and he also has a conduct disorder. He exhibits a conduct disorder, and so the intermittent explosive disorder criteria should be used as explained below. First, consider whether he can control his aggressive nature as exhibited in either Physical or verbal aggression. Ascertain whether over the last three months he presented an aggressive character. Include it if it averagely happened twice in each week or violent behavior was leading to a destruction of property or assault. Check whether this happened over three times in a span of one year. If so, include it in the diagnosis. (Nussbaum, 2013) Second, consider the levels of aggression and relate them to any possible psychosocial stressors. Ascertain whether there could be particular events or happenings that trigger the aggression. When the recurrent outbursts occur, it should be clear whether they come when the patient is angry or not, whether there are particular goals that the patient wants to achieve like getting money or revenging. Some repercussions come with behavioral outbursts that may lead to legal action and processes and also personally get distressed, as a procedure the patient should give his encounters with such repercussions or consequences. (Nussbaum, 2013) Mr. Roger has an alcohol related disorder that may be making him have behavioral outbursts, hence the need to diagnose this disorder. The following are the symptoms to check out for alcohol-related disorders. First, if it is taken in much more quantities than expected. Second, there are unsuccessful attempts to reduce or stop consumption. Third, recurrent alcohol use resulting to misbehavior. Fourth, continued taking despite the knowledge of the effects thereof. Severity specifiers are used in place of addiction and abuse, two and three criteria signify mild, four and five signify moderate and above six is severe. (Gabbard O.G, 2014). Mr. Roger is struggling with partial paralysis, but the condition is being taken care of well since he stays in an assisted living facility. He, on the other hand, portrays a behavioral disorder that is said to come up after taking alcohol. From the statement, he has signs of depression. This can be attributed to one source of income, loss of wife and his illness. This mental disorder needs to be addressed and controlled. He is using alcohol while receiving treatment that is illegal. Treatment plan In coming up with a treatment plan, objectives must be laid down and accompanying goals. This has to be both for the short term and the long term. To come up with these goals and objectives, the diagnostic results are applied by the practitioner. For an effective plan to be drawn the patient should be involved because it is a situation that he wants to pull himself out. Mr. Roger may be taking alcohol, but he is not letting that out easily though there are allegations that he smells of alcohol after going to church. The treatment cannot begin while the patient is not willing to give information about his drinking habits. The client’s immediate problem should be captured in the short term goals of the treatment plan. (Dziegielewski S.F, 2015) Alcohol use disorder treatment objectives should be clear since cases of relapse have been reported severally. Efforts should be made to make sure that the patient is motivated to keep up with the healing process. Conditions that are related to alcoholism should be taken into consideration because treatment may start and lead to greater damage to the brain. The type of medication to be used should not alter the normal functioning of the body. Mr. Roger has partial paralysis, the type of medication to be administered should not worsen his condition. Considering this at the planning level of treatment is appropriate in order not to waste resources and end up causing more harm to the patient. The physician should not be judgmental and should be persistent in counseling the patient. (Sadok J.B, Kaplan H.I &Sadock V.A, 2007) Goals In the treatment plan the goals include, i. Total abstinence. ii. Medical assessment. iii. Introducing ways the patient is going to cope or building on the already existing strengths. Objectives i. To evaluate the amount of the patient is using. ii. To mitigate the risks, that arise from alcohol use. iii. To establish systems, that will support the patient during the recovery period. iv. To examine the progress of recovery. (Dziegielewski S.F, 2015) Mr. Roger has various strengths that can help in the treatment plan laid above. First, he is cooperative. Being cooperative makes it easier for the practitioner to carry out the treatment since it is easier to explain to him the kind of treatment that is to be given without much resistance from him. Second, he is not dependent on alcohol. He takes it once in a while, and so he does not have a severe disorder. Third, he has the family support. At times, his daughters and grandchildren visit him and take him out to have fun. Having a close family makes the patient feel cared for and wanted, and this reduces depression. Lastly, he has faith since he goes to church so he is hopeful that his problems will end someday. The treatment theory suitable for Roger is integrated psychosocial treatment. The treatment is appropriate because people around him have information about his character. The integrated psychosocial treatment is one of the current treatments that have been developed for such cases as Roger’s. Psychotherapies conducted here are efficient since there is reliance on the available information about the patient’s use of alcohol. It is also useful in controlling a relapse. (American Psychiatric Association, 2006) The following are questions to be asked regarding the client. i. Whether he takes alcohol in larger amounts than expected. ii. Whether he has unsuccessful efforts to cut down on drinking. iii. If he has a high desire to drink alcohol. iv. Continued use of alcohol even with the behavioral outbursts. v. Ascertain whether he takes alcohol for longer than expected. vi. Whether he has failed to fulfill an important obligation due to being drunk. (Gabbard O.G, 2014) To conclude, Roger’s condition is treatable bya good clinician handling him since he is cooperative and willing to be treated. References American psychiatric association (2006).American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders, Washington DC.American Psychiatric Publishing. Dziegielewski S. F. (2015) DSM-5 in Action. New Jersey. John Wiley &Sons Inc. Gabbard G. O. (2014).Gabbard’sTreatments of Psychiatric Disorders(5th ed).Washington DC. American Psychiatric Publishing. Nussbaum A. M. (2013).The Pocket Guide to the DSM-5 Diagnostic Exam, Washington DC American Psychiatric Publishing. Sadok B.J, Kaplan H.I. &Sadock V.A. (2007).Kaplan and Sadock’s Synopsis of Psychiatry:Behavioral Sciences/Clinical Psychiatry (10thed).Philadelphia. Lippincott Williams & Wilkins.]]>

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