Reflective Journal –
stabilizing a Substance Abuse patient,
In your journal responses, please attempt to link your thoughtful responses to the
experiences provided in online meetings, your psychotherapeutic readings, and the
other related materials, as well as what is happening in your day-to-day life. Think
about and reflect upon how the ideas discussed and ideas in the readings can be
incorporated into your individual practice and develop your reflective entry around
this. The purpose of this assignment is to challenge the student to reflect on the contextual
matter, how this interplays with their future vision of their practice, and their interface
with barriers to optimal care. Ethical and moral dilemmas may also be a part of your
reflection and observations. This is a feeling assignment. Reflect on how you are
A SOAP note for psychiatry is a little different than a SOAP note for a medical patient, but the basic format and premise is the same. It is communication between the treating clinician and the next treating clinician as well as other members of the care team. It is also something that the insurance company or payor source may want to look at to determine if the patient requires this level of care. A SOAP note is a part of the Patient care Documentation (Chart), a legal document, and is to be treated as such. It is not the initial documentation on a patient, it is after the patient has been seen and an initial psychiatric evaluation has been done.
This is a pretty good example for you to use for preparing a SOAP NOTE. If your facility uses one you like better, that is fine. Following the information gleaned from a patient interview, a chart review; upload your note to this Blackboard dropbox.
A Transfer Summary is created when a patient’s case is being transferred to another facility for various reasons and referred to another provider either by change of level of care, decision by insurance, decision by family, type of care required, or change of program; to name a few. Sometimes you as the provider are okay with this transition and sometimes not, but you must provide the necessary information whether or not you are in favor of this move. It is a communication between the treating clinician and the next person/agency involved. The Transfer Summary provides closure on your part but not for the patient. Closures can occur in two ways, written and/or oral. In this assignment, students will produce either a written or an oral transfer summary to assist them in practice when a Transfer Summary is appropriate. A Transfer Summary is a part of the Patient care Documentation (Chart), a legal document and is to be treated as such.TRANSFER SUMMARYSUMMARY OF TREATMENT PLANNING:Two major problems were identified at the admission of MJ 15 year old adolescent male
1. Mood swings.
2. Oppositional and defiant behavior.
A Discharge Summary is created when a patient’s case is closed and referred to another provider either by discharge from an inpatient or outpatient program. It is a communication between the treating clinician and the next person/agency involved. It also occurs if a patient is deceased. The Discharge Summary provides closure. Closures can occur in two ways, written and/or oral. In this assignment, students will produce either a written or an oral discharge summary to assist them in practice when a Discharge Summary is appropriate. A Discharge Summary is a part of the Patient care Documentation (Chart), a legal document and is to be treated as such.
DISCHARGE DISPOSITION: The patient CJ is a 24-year-old female with a history of bipolar affective disorder.
F90.2 Schizoaffective disorder, bipolar type.