In Topic 4, 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?
Subjective: Client complains about extreme stress caused by effort having to be made to do well in Engineering classes and needing to attend tutorials. The client complains about not feeling supported and feeling pressure to do well from their family. The client has been self harming almost daily, drinking five days a week. The client complains about struggling to make friends and feeling pressured to drink to fit in. The client reports a prior history of self-harm when stressed with school work.
Objective: Client appears anxious, visibly distraught as evidenced by the initial refusal to sit down and pacing in front of the desk for several minutes before finally sitting down. Lab work and physical exam has not yet been confirmed.
Assessment/Problem List: The client appears to lack healthy coping skills necessary to manage stressors. The client uses substance and self-harm (cutting) to alleviate stress. Provisional diagnosis: F10.20 Alcohol Use Disorder, Severe and F43.23 Adjustment Disorder with mixed anxiety and depressed mood. The client’s recent suicide attempt warrants the client be admitted for direct observation under hospitalization until the client is stabilized.
Plan: Initiate weekly counseling, post client stabilization post hospitalization for recent suicide attempt. Client to engage in weekly CBT and mindfulness based approaches in counseling.
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