Complete SOAP and PIE case notes for the following two cases.
- Alaina is an 85-year-old African American woman who lives alone with her small dog, Gus. Alaina lost her husband a few years ago after a painful battle with prostate cancer. Alaina and her husband had a wonderful, supportive relationship. Alaina cared for her husband throughout his illness, but it took a toll on her both physically and emotionally. She still struggles with grief over his death and has days where she still cries uncontrollably. Her family checks in on her often but struggle with knowing what to do on days she is experiencing deep sadness. Gus has been a great support for her and has been critical in helping her get through some of her hardest times. Alaina is aware of the changes that occurred over the years in the neighborhood where she has so many memories and enjoyed life for so long. Despite the increasing crime, she continues to feel safe in her home as she maintains relationships with her friends who live close by and with the support of her church family, who also check in on her weekly. Alaina has been experiencing some increased health problems recently. She suffers from back pains, osteoporosis, and diabetes. She has been prescribed several medications to manage her health issues and has been experiencing increased side effects due to the new medicines. Alaina works hard to maintain her daily routine, but her friends have noticed that she has started to engage in some unusual behaviors, such as walking without Gus or being out alone after dark, as well as self-report she has had some dizzy spells and was falling more. Her friends have shared their concerns with her children, and they have decided to meet with their mother to find out more information to determine how to best support her needs.
- George is brought to a community outpatient mental health clinic due to his parent’s observation that he is “not acting like a normal 13-year-old.” George’s parents report that he is failing school, has no peer group, and he is often angry at home, “lashing out at this younger brother and sister.” They brought him to the clinic because they think he is suffering from the same mental illness his mother has, and the last straw was that he was found with marijuana in his bedroom. The family reports a long and detailed family history of substance abuse. And they report that George’s mother lives with debilitating symptoms of anxiety and intermittent depressive episodes. When you talk to George, he reports “My parents are exaggerating. I have friends. And, my little brother and sister are annoying, and are always bothering me and stealing my stuff. Besides, I prefer hanging out by myself.
Case 1: Alaina
SOAP Notes
Subjective:
- Alaina is an 85-year-old African American woman.
- She lives alone with her dog, Gus.
- She is experiencing grief over the loss of her husband, who died a few years ago.
- Reports days of uncontrollable crying.
- Family checks in often but is unsure how to support her during deep sadness.
- Increased health problems: back pains, osteoporosis, diabetes.
- Experiencing increased side effects from new medications.
- Friends report unusual behaviors (walking without Gus, being out alone after dark).
- Self-reports dizzy spells and increased falls.
Objective:
- Appears physically frail.
- Evidence of medication side effects (dizziness).
- Reports of unusual behaviors (potential safety risk).
- Reports increased falls.
Assessment:
- Grief and potential depression due to loss of husband.
- Increased health problems and side effects from medications.
- Safety concerns due to dizziness and falls.
- Social support system present (family, friends, church).
Plan:
- Conduct a thorough assessment of her mental health to evaluate for depression.
- Review and adjust medications to manage side effects.
- Implement fall prevention strategies (home safety assessment, mobility aids).
- Encourage family involvement and educate them on supporting her emotional needs.
- Refer to grief counseling or support groups.
- Regular follow-up appointments to monitor her physical and mental health.
PIE Notes
Problem:
- Grief and potential depression.
- Increased health problems and medication side effects.
- Safety concerns due to dizziness and falls.
Intervention:
- Assess for depression and grief.
- Review and adjust medications.
- Implement fall prevention strategies.
- Educate family on emotional support.
- Refer to grief counseling.
- Schedule regular follow-up appointments.
Evaluation:
- Ongoing assessment of mental health status.
- Monitor for improvement in side effects and manage as necessary.
- Evaluate effectiveness of fall prevention strategies.
- Assess family involvement and support.
- Follow-up on participation in grief counseling or support groups.
Case 2: George
SOAP Notes
Subjective:
- George is a 13-year-old boy brought to the clinic by his parents.
- Parents report failing school, no peer group, and anger issues at home.
- Found with marijuana in his bedroom.
- Family history of substance abuse.
- Mother has anxiety and intermittent depressive episodes.
- George claims parents are exaggerating and reports having friends, although he prefers being alone.
- States younger siblings are annoying and bother him.
Objective:
- No visible signs of physical illness or distress.
- Reports from parents indicate behavioral issues (anger, isolation, substance use).
- Family history of mental illness and substance abuse.
Assessment:
- Potential behavioral and emotional issues.
- Risk of substance abuse given family history and personal use.
- Possible impact of mother’s mental health on George’s behavior.
- Need for comprehensive mental health assessment.
Plan:
- Conduct a thorough psychological evaluation to assess for underlying mental health issues.
- Screen for substance abuse and provide appropriate interventions.
- Develop a behavior management plan involving the family.
- Provide family counseling to address dynamics and support strategies.
- Coordinate with school to monitor academic performance and provide support.
- Schedule regular follow-up appointments to monitor progress.
PIE Notes
Problem:
- Behavioral and emotional issues.
- Risk of substance abuse.
- Impact of family dynamics on behavior.
Intervention:
- Conduct psychological evaluation.
- Screen for substance abuse.
- Develop a behavior management plan.
- Provide family counseling.
- Coordinate with school for academic support.
- Schedule regular follow-up appointments.
Evaluation:
- Monitor for improvement in behavior and emotional health.
- Assess effectiveness of substance abuse interventions.
- Evaluate family counseling outcomes.
- Track academic performance and school involvement.
- Regularly reassess and adjust the care plan as needed.