SOAP Notes Health, Medicine, Nursing Case Study Paper (Case Study Sample)
Unit VII Case Study
Imagine that you are working in a small mental health component of nonprofit organization in your community. This department can be a part of the nonprofit you have created in earlier units in the course if it fits within the scope of people who you serve, or you can imagine that you are working with another nonprofit in your community if it does not.
Read the case of Helena, which is in the instructions below. Modeling after the notes taken for the case of Sheryl in the Unit VII Lesson, create professional mental health notes using SOAP notes as discussed in this unit.
At the end of your case study, include one or two reflection paragraphs about the assignment. If an emotionally distraught person came into your nonprofit and started speaking with you, how could you use the SOAP notes format to pass along information to a counselor and get that person the help he or she needs? If the SOAP notes assignment is outside your field of study, reflect on how this assignment challenged you.
See the case of Helena below.
Helena reported to her first session of court-ordered therapy on May 15. I had already read the judge’s instructions that she should be seen weekly for 6 months or the length of her term in the county detention center. When she walked into the therapy room, she was charismatic and well-spoken. Her history indicated a string of boyfriends and some violent behavior when something about the relationship did not go as she wanted; it is likely that her charm factored into her storied romantic history.
Helena speaks fluent English as well as Danish; she is the daughter of Danish immigrants who moved to the United States approximately 15 years ago to explore small business opportunities. I addressed legal/ethical questions early on in the initial session given history of violent tendencies; she reports no current wish to harm herself or others and would be limited in doing so due to her present incarceration.
When asked about these prior incidents of violence, she states that they were not premeditated but were the result of the treatment she received from her boyfriends. She described living with some and dating others more casually. According to police records, several relationships ended when Helena became violent or engaged in reckless behavior. In the final relationship, she reportedly drove a car into the side of her lover’s house when he admitted to her that he had been in eight prior sexual relationships before meeting her. Probed on these points, Helena expresses an earnest feeling of having been insulted and laughs off the aggressive behavior. (It was this final event that brought her to the detention center for a currently unspecified period of time while she awaits trial.)
Helena indicates that she is the second of two children and that she and her brother are close. She laughs as she states that he is not as good at attracting men as she is but that they do have a history of playing games to see who can snag a potential partner first. As she says this, she pulls hair out of her eyes and leans forward, smiling. She says that a broken bone from childhood was the last time she was really treated for anything before now, except for routine dental and physical exams through high school. She was underemployed as a waitress prior to incarceration and has not kept up with physical examinations since graduating 4 years ago (intake paperwork indicates she is 22 years of age). She indicates no dependency on drugs or alcohol, but the arresting officer did take a positive reading for alcohol after the incident with the car.
Given the time based on her stay at this facility, I would like to explore the possibility of a Cluster B personality disorder given her erratic reactions and possible lack of respect for others. I specifically want to consider histrionic personality disorder given her mannerisms and the way she seems to navigate life with a very charming effect.
Part I: Your completed SOAP notes and reflection component should be at least two pages in length. Outside sources may be included, but they are not required for this assignment. If you do choose to use any outside sources, be sure to use APA format to document those sources with in-text citations and on a references page. Remember that your assignment does not need to include an APA title page. Be sure that you are uploading the Unit VII Case Study for grading.
Unit VII Case Study: Soap Notes
Unit VII Case Study: Soap Notes
Subjective: The patient, Helena, reported for therapy under the direction of the court, which provided for weekly therapeutic visits for six months or the length of her term in the county. She is a Danish immigrants’ daughter who comes to the U.S about15 years ago to explore small business opportunities. Apart from court-directed therapy of being violent, she reports no other complaint. She reports no recent history of health concerns, with only exception routine physical and dental checkups and cited bone breakage, which occurred during childhood days. She talked about having a string about boyfriends and narrated about some form of violence in such a relationship when things went south. She talks about the casual date of other boyfriends even when she already has one.
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