ADHD SOAP Note example

ADHD SOAP Note example

ADHD SOAP Note example
SOAP Note for Attention-Deficit/ Hyperactivity Disorder (ADHD) in an 8 Year-Old Caucasian Boy
Patient: A.F.                Age: 8             Gender: Male              Race: Caucasian
SUBJECTIVE
CC: The mother to the eight-year old boy states that her son has been displaying abnormal behavior in that he is continually moving around and is unable to concentrate for long on any task. She has also received reports from school that the boy is excessively disruptive and cannot finish work given to him by the teachers.
HPI: The patient is an 8 year-old Caucasian male child with hyperactivity, inattention, and impulsivity that started one month ago and is becoming more intense. It is not associated with a lack of understanding instructions on the part of the child. The mother reports that the child is also not really defiant. The symptoms occur at any time of the day and are only momentarily relieved by reprimanding. The mother rates the severity of the symptoms at 8/10 on a scale of 1-10 ADHD SOAP Note example.
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Current medications: The child is not on any medications at the moment.
Allergies: He is allergic to penicillin. Mother reports that he is not allergic to any other medication, foods, or environmental factors.
Past Medical History: He had pneumonia at age 3 which was successfully treated as an in-patient. Given BCG, tetanus/ Diptheria/ Pertussis, and measles vaccines (2012-2013), influenza vaccine (2017), and pneumonia vaccine (2015). The mother reports that he has no history of malaria or meningitis. He also has not suffered any head injury in the past.
Social History: The boy is the second born in a family of four. The elder sibling is a girl aged twelve and she has no medical or mental problems. The father is a computer engineer and the mother is a nurse. The father smokes but drinks only occasionally. The mother neither drinks nor smokes.
Family History: There is no history of mental illness in the family, both from the father’s side and the mother’s side.
Review of Systems (ROS)
Constitutionals: Patient denies feeling hot/ warm. Mother also denies any weight loss in the boy. She however reports excessive hyperactivity, impulsivity, and inattention not accompanied by lack of comprehension. He has no sleep difficulties.
HEENT: The boy reports no dry eyes, itching, or pain. He has no photophobia. He reports no hearing loss, no tinnitus, and is not sneezing. He also has no runny nose and no sore throat.
Respiratory: He has no difficulty in breathing, is not coughing, and has no phlegm.
Cardiovascular: He has no chest discomfort, pain, or palpitations.
Gastrointestinal: Mother reports no vomiting, lack of appetite, or diarrhea.
Genitourinary: The boy denies any burning sensation on urination. No polyuria.
Musculoskeletal: He denies any muscle pain or stiffness.
Neurologic: He denies any headache, instability while walking, numbness, or a change in bladder and/ or bowel control.
Psychiatric: Mother reports that the child has a history of abnormal lack of concentration and hyperactivity. She however denies noting any depressive or anxiety symptoms in him.
Hematologic/ Lymphatic: Both mother and son deny any abnormal bleeding or fatigue. No enlarged nodes.
Endocrine: Mother and son deny excessive urination (polyuria) or excessive water intake (polydipsia). They also deny excessive sweating or heat intolerance.
Allergic/ Immunologic: Mother denies any history of eczema or asthma. Also denies any other seasonal allergies.
OBJECTIVE
Constitutional: The boy is well-groomed and well-nourished. Vital signs: Heart rate: 90; Respiratory rate: 20; Temperature: 98.6°F; Blood pressure: 110/70; Height: 51 inches; Weight: 56 lb; BMI: 15.1 (BMI-for-age at the 33rd percentile). The child has healthy weight (CDC, 2018).
HEENT: Head normocephalic and atraumatic with normal contours. Both pupils equal, round, and reactive to light and accommodation (PERRLA). Intact extraocular muscles. Nasal sinus passages non-tender on palpation. Intact tympanic membrane with no discharge or redness. No halitosis. No exudates in throat.
Neurologic: Cranial nerves are intact with normal symmetric reflexes. Alert and oriented in time, space, person, and place. No motor, sensory, or focal deficit noted.
Psychiatric: Mood congruent with content. Responses hasty but appropriate. Appropriately groomed. Fidgety and restless. Unable to maintain eye contact and concentrate for long.
Diagnostic Laboratory and other Tests: (1) DSM-5 criteria for ADHD. The boy met criteria 1 and 2 for inattention together with hyperactivity and impulsivity (APA, 2013); (2) Blood lead metal levels to rule out lead poisoning which causes similar symptoms (Stahl, 2013); (3) Swanson, Nolan, and Pelham version IV scale teacher form or SNAP-IV to confirm ADHD (Swanson, 2013); (4) Full blood count to rule out any systemic infections (Hammer & McPhee, 2018; Huether & McCance, 2017).
ASSESSMENT
            The differential diagnoses are:

ADHD with combined presentation (314.01[F90.2]). This is the first and most likely diagnosis because the child meets the DSM-5 diagnostic criteria for ADHD (APA, 2013; Stahl, 2013).
Autism spectrum disorder (APA, 2013).
Oppositional defiant disorder (APA, 2013).

PLAN

Behavioral therapy for both the child and the mother, social skills training, cognitive behavioral therapy, and psycho-education (Corey, 2013).
Medication (stimulant). Start methylphenidate (Focalin) 2.5 mg twice a day (Katzung, 2018; Stahl, 2017).
Alternative therapies: (1) A healthy and balanced diet, and (2) Omega-3 vitamin supplements (NHS, 2018).

Health Promotion
The mother should join a support group of parents with children suffering from ADHD in order not to feel as an isolated case. She should also be familiar with the side effects of the Focalin so that she can report them promptly when they occur. Lastly, she should talk to the teachers at school and let them know what her son is suffering from and that he is on medication and therapy (NHS, 2018).
Follow-Up
This will be after four weeks to assess the response to medication and therapy instituted.
Reflection
This experience teaches that ADHD is a condition that can affect the life of a child with lasting implications. It may also be tricky to diagnose because there are other conditions that closely mimic it. Another lesson learnt is that behavioral therapy is an important part of the management of this condition. In this, both the parents and the child should undergo therapy for the best chance of success in remission.     
 
 
 
References
American Psychiatric Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5th ed. Arlington, VA: Author.
Centres for Disease Control and Prevention [CDC] (October 22, 2018). BMI percentile calculator for child and teen. Retrieved 1 April 2020 from https://www.cdc.gov/healthyweight/bmi/calculator.html
Corey, G. (2013). Theory and practice of counseling and psychotherapy, 9th ed. Belmont, CA: Cengage Learning.
Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8th ed. New York, NY: McGraw-Hill Education.
Huether, S.E. & McCance, K.L. (2017). Understanding pathophysiology, 6th ed. St. Louis, MO: Elsevier, Inc.
Katzung, B.G. (Ed) (2018). Basic and clinical pharmacology, 14th ed. New York, NY: McGraw-Hill Education.
NHS (May 30, 2018). Attention-deficit/ hyperactivity disorder (ADHD). Retrieved 1 April 2020 from https://www.nhs.uk/conditions/attention-deficit-hyperactivity-disorder-adhd/treatment/
Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6th ed. New York, NY: Cambridge University Press.
Stahl, S.M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical application, 4th ed. New York, NY: Cambridge University Press.
Swanson, J.M. (2013). Swanson, Nolan and Pelham Teacher and Parent Rating Scale (Snap-IV). Retrieved 1 April 2020 from https://www.mcpap.com/pdf/SNAPIV.pdf
 
Assignment 1: Practicum – SOAP Note #2
Select a patient who you examined during the last 3 weeks. ( we can put 8 years old boy with attention deficit hyperactivity disorder). With this patient in mind, address the following in a SOAP Note:
Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent, as well as possible reasons for these discrepancies.
Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
 

Excellent
Good
Fair
Poor

Subjective: CC
(1 point)
1 (1%) – 1 (1%)
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)

Subjective: Pertinent positives LOCATES
(10 points)
9 (9%) – 10 (10%)
Includes thorough, accurate, and pertinent positives LOCATES ADHD SOAP Note example
8 (8%) – 8 (8%)
Includes accurate and pertinent positives LOCATES
7 (7%) – 7 (7%)
Includes positives LOCATES
0 (0%) – 6 (6%)
Does not include positives LOCATES or positives LOCATES are not pertinent

Subjective: Pertinent negatives (from ROS)
(10 points)
9 (9%) – 10 (10%)
Includes thorough, accurate, and pertinent negatives (from ROS)
8 (8%) – 8 (8%)
Includes accurate and pertinent negatives (from ROS)
7 (7%) – 7 (7%)
Includes negatives (from ROS)
0 (0%) – 6 (6%)
Does not include negatives (from ROS) or negatives (from ROS) are not pertinent

Subjective: Pertinent PMH, SH, and FH
(3 points)
0 (0%) – 3 (3%)
Includes thorough, accurate, and pertinent PMH, SH, and FH
0 (0%) – 0 (0%)
NA
2 (2%) – 2 (2%)
Includes PMH, SH, and FH
0 (0%) – 1 (1%)
Does not include PMH, SH, and FH or PMH, SH, and FH are not pertinent

Subjective: Medications and drug/food allergies are not included
(1 point)
1 (1%) – 1 (1%)
Does not include medications and drug/food allergies
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
Includes medications and drug/food allergies

Objective: VS including BMI
(2 points)
2 (2%) – 2 (2%)
Includes VS including BMI
0 (0%) – 0 (0%)
NA ADHD SOAP Note example
0 (0%) – 0 (0%)
NA
0 (0%) – 1 (1%)
Does not include VS including BMI

Objective: Heart and lungs
(1 point)
0 (0%) – 1 (1%)
Includes heart and lungs
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
Does not include heart and lungs

Objective: Systems or specialty exam techniques that are not necessary to arrive at a diagnosis are included.
(5 points)
5 (5%) – 5 (5%)
Includes thorough explanation of systems or specialty exam techniques that are not necessary to arrive at a diagnosis
4 (4%) – 4 (4%)
Includes systems or specialty exam techniques that are not necessary to arrive at a diagnosis
0 (0%) – 0 (0%)
NA
0 (0%) – 3 (3%)
Does not include systems or specialty exam techniques that are not necessary to arrive at a diagnosis

Objective: Systems or specialty exam techniques that are necessary to arrive at your diagnosis are omitted.
(10 points)
9 (9%) – 10 (10%)
Omits systems or specialty exam techniques that are necessary to arrive at your diagnosis
8 (8%) – 8 (8%)
Omits most systems or specialty exam techniques that are necessary to arrive at your diagnosis
7 (7%) – 7 (7%)
Omits some systems or specialty exam techniques that are necessary to arrive at your diagnosis
0 (0%) – 6 (6%)
Does not omit systems or specialty exam techniques that are necessary to arrive at your diagnosis

Objective: Diagnostic test results
(2 points)
2 (2%) – 2 (2%)
Includes diagnostic test results
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
NA
0 (0%) – 1 (1%)
Does not include diagnostic test results

Assessment: Priority Diagnosis
(30 points – 10 points for each priority diagnosis. If less than 3 are appropriate to include – simply no other diagnoses to consider – you will receive all 30 points. Please do not “stretch” to find 3 if they are not actual possibilities.)
27 (27%) – 30 (30%)
Includes three appropriate priority diagnoses
24 (24%) – 26 (26%)
Includes three appropriate priority diagnoses but some are incorrect or missing
22 (22%) – 23 (23%)
Includes fewer than three priority diagnoses but some are incorrect or missing
0 (0%) – 21 (21%)
Does not include three appropriate diagnoses

Plan: Medications discontinued (“d/c lisinopril 10 mg daily”)
(1 point)
1 (1%) – 1 (1%)
Includes discontinued medications
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
Does not include discontinued medications

Plan: Medications started (“start Avapro 150 mg daily”)
(2 points)
2 (2%) – 2 (2%)
Includes medications started
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
NA
0 (0%) – 1 (1%)
Does not include medications started

Plan: Alternative therapies if appropriate (1 point)
0 (0%) – 1 (1%)
Includes alternative therapies if appropriate ADHD SOAP Note example
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
Does not include alternative therapies if appropriate

Plan: Health Promotion strategies – patient/family education
(3 points)
0 (0%) – 3 (3%)
Includes health promotion strategies – patient/family education
0 (0%) – 0 (0%)
NA
2 (2%) – 2 (2%)
Includes health promotion strategies – patient/family education, but may not be entirely appropriate for the patient/family
0 (0%) – 1 (1%)
Does not include health promotion strategies – patient/family education

Plan: Disease Prevention strategies with timeframe if appropriate
(3 points)
3 (3%) – 3 (3%)
Includes disease prevention strategies with timeframe if appropriate
0 (0%) – 0 (0%)
NA
2 (2%) – 2 (2%)
Includes disease prevention strategies, but does not include timeframe or disease prevention strategies are not appropriate
0 (0%) – 1 (1%)
Does not include disease prevention strategies

Plan: Diagnostic tests ordered with timeframe (now, in 2 weeks, prior to f/u visit in 3 months)
(3 points)
3 (3%) – 3 (3%)
Includes appropriate diagnostic tests ordered with timeframe
0 (0%) – 0 (0%)
NA
2 (2%) – 2 (2%)
Includes diagnostic tests but they may not be appropriate, or the timeframe is incorrect or not included
0 (0%) – 1 (1%)
Does not include diagnostic tests

Plan: Referrals or consultations if appropriate
(1 point)
1 (1%) – 1 (1%)
Includes referrals or consultations if appropriate
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
Does not include referrals or consultations if appropriate

Plan: Follow-up interval
(1 point)
1 (1%) – 1 (1%)
Includes follow-up interval
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
NA
0 (0%) – 0 (0%)
Does not include follow-up interval

Reflection Notes: What did you learn from this experience? Any ah-ha’s?
(10 points)
0 (0%) – 10 (10%)
Response includes thoughtful and insightful explanation of significant learnings
8 (8%) – 8 (8%)
Response includes thoughtful and insightful explanation of learnings ADHD SOAP Note example
7 (7%) – 7 (7%)
Response includes explanation of learnings
0 (0%) – 6 (6%)
Response does not include explanation of learnings

Total Points: 100

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