Self injurious patient and soap note

Y
You are seeing a current client for a follow-up session with new developments of self-harm. This is not an initial interview. For this session, focus on the psychodynamic therapy modality to engage with the teen. Use empathy and other skills you have reviewed..
 
Psychodynamic psychotherapy This type of therapy helps individuals explore issues lurking at the subconscious or unconscious level that often stem from negative childhood experiences and painful memories.
A 17-year-old female patient named Stella Jess, who recently broke up with her boyfriend, reveals she has been cutting her arms. While rolling up her sleeves to display the cuts, she expresses suicidal ideation. She has a suicidal plan, overdosing on her depression medication (Prozac) and alcohol, but says she doubts she would ever actually attempt to take her life. She reports no serious previous attempts. Her history includes some neglect from her parents when she was a younger child, and she now lives with her grandmother. Her mother is still involved in her life, but not on a daily basis. She is an A student, does not miss school, and states she has a group of close friends with whom she enjoys spending free time.
Vitals:BP: 122/68HR: 74R: 18T: 97O2: 99%Pain: 2 on 010 scale
Consent to treat the minor signed by parents.
                                                              II
Instructions
Your reflection should address all of the following questions with between 750 to 1,000 words. Appropriate spelling, grammar, and punctuation are required. Complete sentences are expected. All writing should be in your own words. Use APA references as needed to support your ideas; there is no requirement on the number of references to include. Be sure to use APA format.

SOAPNote:

Fill in the SOAP note in the template based on your session visit. This should be a follow-up note, as this session was NOT an initial interview.
Create a Session Reflection & SOAP Note based on your session with the client.

 
 

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