Problem- Focused SOAP Note

Psychiatric patient older than 65 y/o. Below is a template for this assignment.

Demographic Data

• Patient’s age and patient’s gender identity

IT MUST BE HIPAA compliant.

Subjective

• Chief Complaint (CC): Place the patient’s CC complaint in Quotes
• History of Present Illness (HPI): Reason for an appointment today. The events that led to hospitalization or clinic visits today. Include symptoms, relieving factors, and past compliance or non-compliance with medications Any adverse effects from past medication use Sleep patterns – number of hours of sleep per day, early wakefulness, inability to initiate sleep, inability to stay asleep, etc. Suicide or homicide thoughts present Any self-care or Activity of Daily Living (ADL) such as eating, drinking liquids, self-care deficits, or issues noted? Presence/description of psychosis (if psychosis, command or non-command)
• Past Psychiatric History (PSH): Past psychiatric diagnoses Past hospitalizations Past psychiatric medications use Any non-compliance issues in the past? Any meds that didn’t work for this patient?
• Family History of Psychiatric Conditions or Diagnoses: Mother/father, siblings, grandparents, or direct relatives
• Social History:  Include nutrition, exercise, substance use (details of use), sexual history/preference, occupation (type), highest school achievement, financial problems, legal issues, children, and history of personal abuse (including sexual, emotional, or physical).
• Allergies: To medications, foods, chemicals, and others.

Review of Systems (ROS) (Physical Complaints): Any physical complaints by the body system? (Respiratory, Cardiac, Renal, etc.)

Objective

Mental Status Exam: This is not a physical exam. Mental Status Exam (MSE)

Assessment (Diagnosis)

• Differentials Two (2) differential diagnoses with ICD-10 codes. Must include rationale using DSM-5 Criteria (Required) Why didn’t you pick these as a major diagnosis?

Working Diagnosis Final or working diagnosis (1), with ICD-10 code. Must include rationale using DSM-5 criteria required – Which symptoms/signs in the DSM-5 the patient matches mostly)

Plan

Treatment Plan(Tx Plan): Pharmacologic: Include complete information for each medication(s) prescribed Refill Provided: Include complete information for each medication(s) refilled

Patient Education: Including specific medication teaching points Was the risk versus benefit of the current treatment plan addressed for meds or treatment Risk versus benefit of non-FDA approved for working diagnosis – Off-label use of medication education to patient addressed?

Prognosis: Make Decision for prognosis: Good, Fair, Poor Provide brief statement lending support for or against the decided prognosis.

Therapy Recommendations: Type(s) of therapy recommended.

Referral/Follow-up: Did you recommend follow-up with a Psychiatrist, PCP, or other specialist or healthcare professionals? When is the subsequent follow-up? Include the rationale for the F/U recommendation or referral.

Reference(s):

• Include American Psychological Association (APA) formatted references.

Include a reference from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) or the accompanying Desk Reference of Diagnostic Criteria from DSM-5.

Problem-focused SOAP Note
Problem-focused SOAP Note
Criteria
Ratings
This criterion is
linked to a Learning
OutcomeSubjective
25 to >20.0 pts
Accomplished
Subjective data, including the
analysis is well organized in a
SOAP format, with C/C, Past
Psychiatric History, Social
History, and other pertinent
past and current diagnostic
details. SOAP Note is
complete, concise, and
relevant with no extraneous
data.
20 to >15.0 pts
Satisfactory
Subjective data, including
the analysis is well
organized in a SOAP
format, with C/C, Past
Psychiatric History, Social
History, and other pertinent
past and current diagnostic
details. Some extraneous
data is present, with one
minor data point missing
15 to >14.0 pts
Needs Improvement
Subjective data, including
the analysis is not well
organized or presented in
a varied format. Required
data is missing. Too much
extraneous data is present,
or 2-3 minor data points
are missing.
14
Un
Sub
inc
ina
org
oth
the
Cri
25 to >20.0 pts
Accomplished
Objective information,
including the Mental Status
Exam MSE) is complete,
concise, well-organized, and
well-written. Includes
pertinent psychiatric
information. They are
organized by MSE list format.
No extraneous information is
included.
20 to >15.0 pts
Satisfactory
Objective information,
including the Mental Status
Exam (MSE) is partially
incomplete, organized, and
satisfactorily written.
Includes pertinent
psychiatric information with
additional extraneous data
included. Somewhat
organized in MSE list
format.
15 to >14.0 pts
Needs Improvement
Objective information,
including the Mental
Status Exam (MSE) is
incomplete and loosely
organized, with
improvements required.
Relevant psychiatric
information is omitted.
14 to
Unsa
Obje
inclu
Statu
disor
prese
no sp
gross
psyc
This criterion is
linked to a Learning
OutcomeObjective
Problem-focused SOAP Note
Criteria
Ratings
This criterion is
linked to a Learning
OutcomeAssessment
25 to >20.0 pts
Accomplished
Assessment with
differential Dignosis are
correct with DSM-5
code(s) and supported by
subjective and objective
data. Includes: 1 working
Dx and 2 Differential Dx.
This criterion is
linked to a Learning
OutcomePlan
Total Points: 100
25 to >20.0 pts
Accomplished
The plan is well-organized,
complete, evidence-based,
and patient-centric. It
comprehensively addresses
each diagnosis and is
individualized to the specific
patient.
20 to >15.0 pts
Satisfactory
Assessment with differential
Dignosis are correct with
DSM-5 code(s) and
supported mainly by
subjective and objective data.
Missing at least one (1)
pertinent subjective ot
objective data for the working
diagnosis is correct.
15 to >14.0 pts
Needs Improvement
Diagnosis and/or Differential
Dx are correct with DSM-5
code(s) and supported
mainly by subjective and
objective data. Or
differential diagnoses are
adequate with an incorrect
working diagnosis.
20 to >15.0 pts
Satisfactory
The plan is organized, complete,
evidence-based, and patientcentric. It comprehensively
addresses each diagnosis and is
individualized to the specific
patient. The plan is missing 1-2
of the required items.
14
Un
All
and
dia
or a
the
obj
15 to >14.0 pts
Needs Improvement
The plan is less organized
and is not based on evidence.
Fails to address each
diagnosis sufficiently or is
not individualized or patientcentric The plan is missing
more than 2 of the required
items.