13.1. Focused SOAP Note – Mental Health Assessment
Choose an abnormal finding related to the content that was covered this week. Examples from this week would include: depression, anxiety, manic episode, grief, anger, adjustment disorder, drug addiction, dementia, etc.
Develop a focused SOAP note for the abnormal finding. You do not need to find a patient to match this finding. The point is for you to think about what the HPI would be, what the rest of the history may look like, what the objective findings will be, the potential differential diagnoses, and the plan. In other words, you are creating the patient scenario and documenting it in SOAP format. Please be sure to include all relevant information and not just the system the abnormal finding is in.