Focused SOAP Note for Petunia Park

 
 SUBJECTIVE CC (chief complaint):the patient indicates that she has been taking medications but believes they are not helping her and squashing who she is. HPI:Petunia Park is a 25-year-old patient who presented with a positive diagnosis of depression. The patient took different medications and had a history of taking and then stopping since they squash who she is and therefore does not need them. Still, they have not effectively managed the clinical symptoms, and she is unwilling to continue with the medication. 
Past Psychiatric History:the patient can recall that she had been told that she suffered from depression and was therefore put on medications. General Statement:the client is cooperative throughout the interview, comprehending and responding to the asked questions. Caregivers (if applicable):The client's mentioned caregiver was the mother and possibly the boyfriend. Hospitalizations: there was a record of a previous hospitalization when the police picked her up for allegedly misbehaving in public, although she believes this was her mother's plan.
 Medication trials:there were several medications the patient had tried and was convinced they were causing her more harm than good. Psychotherapy or Previous Psychiatric
 Diagnosis:there was no indication that the patient had attended any psychotherapy sessions in the past despite being told she suffers from depression. Substance Current Use and 
History:Petunia Park accepted that she had tried taking alcohol previously but did not have a great encounter with it and therefore stopped. She had also tried taking other drugs like cocaine and marijuana, but due to the experience, she has never
3 considered them again. Currently, she is hooked on taking nicotine and is not willing to drop the habit any soon. Family Psychiatric/Substance Use History:there is no history of substance use in the client's family, although there was a positive history of psychiatric conditions among some family members. Psychosocial History:Petunia Park presents as being active, and her social life seems to be full of life. She loves hanging out with friends and participating in activities with total energy