Hi, I have a soap note assigment based on a Symptom Media video. I have watched the video and wrote it in a transcript to remember important parts:

A young woman who experienced a school shooting. I believe that feels guilty because her two best friends were killed and she survived. She reported that she and her friends often ditched class to go text in the bathroom (cell phones are not allowed in class). Mackenzie states that her best friend , Sarah, wanted to go to the bathroom first, but Mackenzie brushed her off stating "My text is more important than yours, you can wait". "If we go together, the teacher will get suspicious". Mackenzie was texting in the school bathroom when the shooter (a male student in the class) started shooting in class.

I need assistance with starting my SOAP note. All of the information is not there, I am not sure if she wants us to make up. Just need help with the info I know with THREE differentials and a diagnosis. I believe that it is PTSD, but cant say for sure because I m not sure how long she has had the symptoms based on the video. I have attached the soap note template and my transcript of the visit. Thank you!

Transcript

The symptom media video is about a young teen, Mackenzie (M). It appears that she has witnessed/been involved in a school shooting.She somewhat blames herself for her friend, Sarah's death.

The interview starts-

The provider has to call her name twice to get her attention "Mackenzie..Mackenzie"

Provider : " Are you tired? "

Mackenzie: (appears tired) "No, I'm not tired at all"

Provider asks, "How are you sleeping?"

She reports. "I slept an hour last night. I turned my headphone up really loud, but the thinking won't stop."

Provider: "Thinking about what happened?"

Mackenzie:" No".

Provider: "What are you thinking about?"

Mackenzie: "I don't want to talk about it...please"

P:" You don't have to talk about anything you don't want to talk about"

Mackenzie: "When I close my eyes, I see them. And when I look at a picture or turn on the t.v, they stay in my head."

P: "Are you talking about seeing your friends or hearing them in your mind?"

Ma: "Since the day after it happened

P" Is what you hear and what you see in your mind is the same as what happened on that day?"

M:" No.... yes. Kinda of- it's like a movie but jumbled. I see...."

P: "Take your time. Sometimes it helps people to talk, share about what they see, hear and see in their mind and remember. But you wait and talk when you are ready."

M:" We had plans about who was going to pick us up to drive. We were supposed to go to the music festival. The night before, she said something that keeps playing in my head over and over. She said, 'we can all snuggle'. It's an inside joke. Stupid. Why did I think about that? Of everything that happened, why that? I can never go to a- I mean they will never go to a.... they won't."

P:" What do they not get to go to?"

M:" The concert"

P:" Do you feel guilty that you survived?"

M:" Yes."

P:" Many people feel guilt when they live and people they care about, love do not live" Can you tell me about where you were on that last day. That day last week?"

M:" I was in biology with them"

P:" Your friend?"

M: (She nods). We skipped class...not the whole class, it just that sometimes we go to the bathroom to text. We aren't allowed to have phones in class.

P:" So you went to the bathroom to text?"

M:" (She nods}

P:" Is that when everything happened?"

M:" I was texting my cousin in Palm Springs- (Mackenzie spaces out)...I'm sorry what did you ask me?"

P: "About what happened when you went to text in the bathroom"

M:" I thought that it was poppers. You know, those things that you throw on the ground and they pop?"

P:" Yes"

M: " I started to go outside to watch and then the screams and the lock down started. I his behind the toilet"

P: " How long were you behind the toilet?"

M:" Over an hour. The police found me. They made me cover my eyes but I felt it"

P:" Felt what?"

M:"The sticky, stickiness underneath my shoes...and that they ground was wet. I knew what it was. It was Lizzie's and Sarah's."

P: "From your friends?"

M: "Yes.

P: "Do those memories and sensations keep coming back playing in your mind and even when you try to block them out?"

M: ({she spaces out)

P: Mackenzie? Mackenzie?

M: (she comes back)

P: "where did you go just then? You didn't seem to be here in this room at this moment."

M: " I don't know."

P:" You appeared to be in some kind of daze. Do you lose focus when your appear like that?"

M: "Sometimes I see myself"

P: "What do you mean?"

M:" I see me on the floor in the bathroom, hear everything that happened. ..."

P: "uh huh?"

M: "And I'm not inside me, I'm outside watching me"

P:" Was it also like that when they were walking you out of the building?"

M:" I wasn't there...I wasn't me...and I see the boy who did it. He's in Ms Dylan's class with Lizzie and Sarah"

P: "That day, did you actually see the boy and your friends in the classroom/"

M:" I don't know the boy, so I don't see his face, I see his shadow. But I see Lizzie and Sarah. I'm with them in that classroom.

P:" So do you feel like you should have been in that classroom with your friends that day?"

M:" I left them to text. I told Sarah to wait, we cant all go to the bathroom at the same time or Ms Dylan will get suspicious. I got a text from my cousin at the same time Sarah saw a text from her mom. I told Sarah she could wait and my message was more important. She rolled her eyes at me which always pisses me off. She started to get out of her seat and before she could, I jumped up and asked Ms Dylan if I could go to the bathroom"

P: "Mackenzie, no matter what you did that day, you are not responsible for Sarah's death. You had no way to foresee what was about to happen."

M:" I told her that her mom could wait. She's still waiting for a reply and she'll never, ever get one. I did that."