Comprehensive Focused Soap Note Nursing Paper Sample

Comprehensive Focused Soap Note Nursing Paper Sample

Subjective Data

CC: “They say I will go over it, but it is not working. I am depressed and feel worthless.”

HPI: VS is a 16-year-old African- American female reporting for routine counseling in her parents’ company. V.S is a victim of sexual assault. She was raped by her cousin, who had come to visit them two months ago. “I keep having flashbacks and nightmares of that night. I cannot sleep properly at night.” She reports trusting her cousin and will never trust a man in her life. The parents report that the client becomes irritable and aggressive towards every male, including her father and those younger than her. “I don’t trust any of them. They are all dogs.” She finds it hard to interact and play with her friends anymore. She is falling behind in class work and hardly concentrates in class or completes her assignments. “They all laugh at me and believe I am cursed or something.” She reports being confused and unable to make simple decisions. Her teacher reports indicate that the client has a poor attention span and prefers to be alone. “Given a chance, I would kill him and myself, but my parents would be sad.” The client has no plan in place to execute her thoughts. She reports her thoughts giving her headaches which go away when she takes Ibuprofen. She takes Sertraline 50mg QD to help with her depression.(Comprehensive Focused Soap Note Nursing Paper Sample)

(Comprehensive Focused Soap Note Nursing Paper Sample)

Past psychiatric diagnosis: Depression.

Current Medications: Ibuprofen 200mg prn, Sertraline 50mg qd.

Medication trials: None.

Substance Use History: Drinks daily to “keep my sanity.” Denise uses tobacco or ETOH.

Family psychiatric/substance use: No psychiatric or substance abuse history.

Social: Raised by both parents. No siblings. She currently lives with her parents. Had an easy childhood. The client is in the 10th grade. (Comprehensive Focused Soap Note Nursing Paper Sample)

Allergies: No known food and drug allergy.


Review of systems (ROS):

GENERAL: 2-pounds weight loss. No fever or chills.

HEENT: No visual changes. No runny nose or congestion. No difficulty swallowing.

SKIN: No itchiness or rushes.(Comprehensive Focused Soap Note Nursing Paper Sample)

CARDIOVASCULAR: No chest discomfort.

RESPIRATORY: No shortness of breath.

GASTROINTESTINAL: No abdominal pain.

GENITOURINARY: No urinary hesitancy or urgency.


NEUROLOGICAL: Reports headache. No dizziness.

HEMATOLOGIC: No hematuria or dysuria.

LYMPHATICS: No history of splenectomy.

ENDOCRINOLOGIC: No polydipsia or polyuria.

Objective Data:

Vital Signs: Stable

Temp: 96.8 F, BP: 110/75, HR: 78, R: 17, O2: 97, Ht: 5’3’’, Wt.: 100lbs, BMI: 17.7 kg/m2

Diagnostic results:

The Child and Adolescent Trauma Screen (CATS):  Meet diagnostic criteria for posttraumatic stress disorder. The Child and Adolescent Trauma Screen is a scale that measures potentially traumatic encounters and posttraumatic symptoms (Sachser et al., 2022).(Comprehensive Focused Soap Note Nursing Paper Sample)

Lab findings: Within normal limits

Alcohol: Positive

Mental Status Examination: VS is a 16-year of African American female who appears the stated age. She is well-groomed and maintains appropriate eye contact. She is moody but conversant with her situation. She appears stressed. Her psychomotor activity is abnormal. She is not delusional and presents no visual or auditory hallucinations. Her affect is blunted and congruent with the stated mood of “depressed.” Her speech is spontaneous with ease of expression. Has normal thought content. Normal cognition, attention, and concentration. No difficulty with abstract thought and broad knowledge. Judgment and insight are good.(Comprehensive Focused Soap Note Nursing Paper Sample)

Diagnostic Impression:

Posttraumatic Stress Disorder. The client’s symptoms meet the diagnostic threshold for posttraumatic stress disorder coded as 309.81 (F43.10). The posttraumatic disorder is characterized by actual or threatened exposure to a traumatic event (American Psychiatric Association, 2019). Affected individuals experience symptoms, including psychological distress, intrusive/involuntary thoughts, avoidance of stressors, marked psychological responses, or flashbacks American Psychiatric Association, 2019). Other symptoms, such as altered mood and hyperactivity after traumatic events, are also common. The client fairly presents these symptoms. Thus, this is the primary diagnosis.(Comprehensive Focused Soap Note Nursing Paper Sample)

Adjustment Disorder. Adjustment disorder is characterized by behavioral and emotional responses to a known stressor and altered moods (American Psychiatric Association, 2019). The disorder is coded as 309.24 (F43.22). These symptoms are clinically significant and affect normal functions. This diagnosis is refuted since the client’s symptoms are better explained by posttraumatic stress disorder.(Comprehensive Focused Soap Note Nursing Paper Sample)

(Comprehensive Focused Soap Note Nursing Paper Sample)

Alcohol Use Disorder. Alcohol use disorder is coded as 303.90 (FI 0.20) and characterized by problematic alcohol consumption, craving for alcohol, constant use, and inability to fulfill routines (American Psychiatric Association, 2019). This diagnosis is refuted since the client’s alcohol consumption is relatively recent, explained by another mental health disorder, and is not taken in large amounts (American Psychiatric Association, 2019).(Comprehensive Focused Soap Note Nursing Paper Sample)



Case Formulation and Treatment Plan 

Stop Ibuprofen – Combined use of Sertraline increases the risk of gastrointestinal adverse effects. Concomitant use of nonsteroidal anti-inflammatory drugs such as Ibuprofen and antidepressants such as sertraline abdominal pain and other related adverse effects on the stomach (Hou et al., 2021).(Comprehensive Focused Soap Note Nursing Paper Sample)

Continue Sertraline and increase the dosage to 100 mg/day. Li et al. (2017) demonstrated that Sertraline is effective in reducing symptoms and well-tolerated by adolescents diagnosed with PSTD. Sertraline is safe for the treatment of PSTD in children and adolescents.(Comprehensive Focused Soap Note Nursing Paper Sample)

Begin ten sessions of trauma-focused cognitive behavioral therapy. Trauma-focused cognitive behavioral therapy effectively treats posttraumatic stress disorder in adolescents (Boland & Verduin, 2021). Trauma-focused cognitive behavioral therapy is acceptable and effective for treating adolescents exposed to interpersonal trauma such as sexual abuse (Peters et al., 2021).(Comprehensive Focused Soap Note Nursing Paper Sample)

Through trauma-focused cognitive behavioral therapy, educate the parents on the status of the patient and their roles in helping the client manage the associated emotional and physiologic reactions. Educate the parents on how to praise, administer medication, seek contingency reinforcement, and troubleshoot various symptoms. Educate the patient on the dangers of alcohol abuse and the need to exercise. Educate the client on relaxation skills and the need for proper dieting.

Return to the clinic after two weeks.

(Comprehensive Focused Soap Note Nursing Paper Sample)


American Psychiatric Association. (2019). Diagnostic and statistical manual of mental disorders (7th ed.). American Psychiatric Publishing, Inc.

Boland, R., & Verduin, M. (2021). Kaplan & Sadock’s Concise Textbook of Clinical Psychiatry. Lippincott Williams & Wilkins.(Comprehensive Focused Soap Note Nursing Paper Sample)

Hou, P. C., Lin, F. J., Lin, S. Y., Hwang, T. J., & Wang, C. C. (2021). Risk of intracranial hemorrhage with concomitant use of antidepressants and nonsteroidal anti-inflammatory drugs: a nested case-control study. Annals of Pharmacotherapy55(8), 941-948.

Li, W., Ma, Y. B., Yang, Q., Li, B. L., Meng, Q. G., & Zhang, Y. (2017). Effect and safety of Sertraline for treat posttraumatic stress disorder: a multicenter randomized controlled study. International Journal of Psychiatry in Clinical Practice21(2), 151-155.

Peters, W., Rice, S., Cohen, J., Murray, L., Schley, C., Alvarez-Jimenez, M., & Bendall, S. (2021). Trauma-focused cognitive–behavioral therapy (TF-CBT) for interpersonal trauma in transitional-aged youth. Psychological Trauma: Theory, Research, Practice, and Policy13(3), 313.

Sachser, C., Berliner, L., Risch, E., Rosner, R., Birkeland, M. S., Eilers, R., … & Jensen, T. K. (2022). The child and Adolescent Trauma Screen 2 (CATS-2)–validation of an instrument to measure DSM-5 and ICD-11 PTSD and complex PTSD in children and adolescents. European Journal of Psychotraumatology13(2), 2105580.

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