This article provides a sample Nursing Post Reply.
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Nursing Post Reply
Reply to #Name
Hello,
Like any other clinical practice, the provision of mental health services must integrate healthcare records that facilitate communication between subsequent providers while at the same time fulfilling the duty of care to the client. Using the SOAP note framework approach enables the provider to gather pertinent information regarding the client. After securing the objective notes, the provider then utilizes differential diagnoses premised on the subject and objective findings before finally outlining a treatment plan to manage the patient’s condition. For example, in your case, the pediatric patient was diagnosed with ADHD combined type (F90.2) as indicated by the presenting symptoms like hyperactive and inattentive behaviors that had lasted for more than 12 months. (Wolraich et al., 2019).
Going through the presenting symptoms, I reached a similar diagnosis while using the mnemonic ATTENTION. The five-year-old patient had difficulty listening to others, tasks requiring sustained mental effort were a challenge, easily distracted; necessary things for tasks are lost. To finish what the boy starts is difficult, is forgetful in daily activities, organization skills lacking, and lastly, not concerned with details (Kadiyala, 2020). The assessment for hyperactivity and impulsivity confirmed through RUN FIDGET, meaning the child runs, climbs, or is restless, has an uninhabited conversation, not able to play quietly, fidgets in the seat, interrupts, difficulty waiting for a turn, gets going as if driven by a motor, evacuates seat unexpectedly and talks excessively. Te Meerman et al. (2017) note that the treatment plan of behavior therapy and lifestyle changes through diet, exercise, and sleep rhymes with pediatric ADHD recommended guidelines that emphasize the use of medications only if the former has failed to produce desired results.
References
Kadiyala, P. K. (2020). Mnemonics for diagnostic criteria of DSM V mental disorders: a scoping review. General psychiatry, 33(3).
Te Meerman, S., Batstra, L., Grietens, H., & Frances, A. (2017). ADHD: a critical update for educational professionals. International Journal of Qualitative Studies on Health and Well-Being, 12(sup1), 1298267.
Wolraich, M. L., Chan, E., Froehlich, T., Lynch, R. L., Bax, A., Redwine, S. T., … & Hagan, J. F. (2019). ADHD diagnosis and treatment guidelines: a historical perspective. Pediatrics, 144(4).
Reply to #Name
Your post on the SOAP note lived up to the billing of the primary goals of the initial psychiatric interview, namely to make a differential diagnosis and develop a treatment plan. A chief complaint heads the subject part of the soap note followed by the history of the presenting illness, the precipitating factors, manifesting symptoms, be they affective, cognitive, or physical, and an accompanying history of substance use and abuse where applicable. One has to admit that using the SOAP note format helps the provider to establish initial rapport very easily in the 28-year-old patient who chiefly complains that he wants to work on staying clean. According to Aboraya et al. (2016), using standardized diagnostic interviews is good but utilizing the Clinician’s interview in Psychiatry (SCIP) is even better. While SDIs was developed for researchers and generated categorical diagnoses, SCIP assesses psychopathology for adults like the patient in your case scenario. In addition to using the SOAP note format, the psychiatrist should employ several techniques to ask the questions necessary to formulate the correct differential diagnosis, establish rapport, and cultivate an atmosphere that nurtures confidence and trust (Silberman et al., 2015).
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Your diagnosis of the patient as having opioid use disorder (Severe) F-11.20 is echoed by abuse et al. (2016), who recommend a diagnosis be made if the client spends a significant amount of time finding, getting, and using opioids. Alternatively, the use of opioids must have caused substantial dysfunction in the fulfillment of vocational and social obligations expected of the patient. The treatment plan that commences with inpatient rehabilitation combined with medications would greatly help. Incorporating patient education and issuing handouts on opioid use disorder is bound to help the patient.
References
Aboraya, A., Nasrallah, H., Muvvala, S., El-Missiry, A., Mansour, H., Hill, C., … & Price, E. C. (2016). The Standard for Clinicians’ Interview in Psychiatry (SCIP): A Clinician-administered Tool with Categorical, Dimensional, and Numeric Output—Conceptual Development, Design, and Description of the SCIP. Innovations in clinical neuroscience, 13(5-6), 31.
Abuse, S., US, M. H. S. A., & Office of the Surgeon General (the US. (2016). Early intervention, treatment, and management of substance use disorders. In Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health [Internet]. US Department of Health and Human Services.
Silberman, E. K., Certa, K., & Kay, A. (2015). The psychiatric interview: settings and techniques. Psychiatry, 1, 34-55.
