Problem-Focused SOAP Note
Submit a Problem-Focused SOAP note of a 16 y/o adolescent suffering mild depression. You must use an actual patient from your clinical practicum. Review the rubric for more information on how your assignment will be graded. Be sure to use the SOAP note template for your program and view the rubric associated with your program for details on how your assignment will be graded.
NURS 682L-B_SOAP Note Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeS (Subjective)
2.5 pts
Accomplished
Meets rubric criteria for Accomplished.
1.5 pts
Satisfactory
Meets rubric criteria for Satisfactory.
1 pts
Needs Improvement
Meets rubric criteria for Needs Improvement.
0 pts
Unsatisfactory
Meets rubric criteria for Unsatisfactory.
2.5 pts
This criterion is linked to a Learning OutcomeO (Objective)
2.5 pts
Accomplished
Meets rubric criteria for Accomplished.
1.5 pts
Satisfactory
Meets rubric criteria for Satisfactory.
1 pts
Needs Improvement
Meets rubric criteria for Needs Improvement.
0 pts
Unsatisfactory
Meets rubric criteria for Unsatisfactory.
2.5 pts
This criterion is linked to a Learning OutcomeA (Assessment)
2.5 pts
Accomplished
Meets rubric criteria for Accomplished.
1.5 pts
Satisfactory
Meets rubric criteria for Satisfactory.
1 pts
Needs Improvement
Meets rubric criteria for Needs Improvement.
0 pts
Unsatisfactory
Meets rubric criteria for Unsatisfactory.
2.5 pts
This criterion is linked to a Learning OutcomeP (Plan)
2.5 pts
Accomplished
Meets rubric criteria for Accomplished.
1.5 pts
Satisfactory
Meets rubric criteria for Satisfactory.
1 pts
Needs Improvement
Meets rubric criteria for Needs Improvement.
0 pts
Unsatisfactory
Meets rubric criteria for Unsatisfactory.
2.5 pt
____________________
S: Subjective
The patient is a 16-year-old female who presents with a 2-week history of depressed mood, loss of interest in usual activities, fatigue, and difficulty concentrating. She reports feeling sad and “down” most days and has lost motivation to engage in hobbies she previously enjoyed like reading and spending time with friends. She denies any suicidal ideation.
O: Objective
Mental status exam reveals depressed affect and mood. She makes poor eye contact. Thought processes are linear and goal-directed. No evidence of hallucinations or delusions.
A: Assessment
Major Depressive Disorder, mild, single episode
P: Plan
Start sertraline 25mg daily for depression
Schedule follow up appointment in 2 weeks to monitor response to medication
Provide patient with psychoeducation about depression and encourage continued engagement in supportive social activities
Recommend daily exercise and keeping a gratitude journal to implement positive coping strategies
