Soap note

Psychiatric SOAP Note Template

Criteria

Clinical Notes

Informed Consent

Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained.

Please select one choice from below statement:

___ Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion).

___ Patient doesn’t have the ability/capacity to respond and appears to not understand the risk, benefits, and (Will review additional consent during treatment plan discussion)

Subjective Data

Verify Patient: Name, Assigned identification number (e.g., medical record number), Date of birth, Phone number, age, marital status, Gender, ethnicity.

Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview.

HPI:

Past Medical and Psychiatric History, Current Medications, Previous Psych Med trials, Allergies

Verify Patient Name and DOB:

Minor: Accompanied by:

Chief Complaint (CC):

“in patient’s own words” reason for visit-restate in case formulation

History of Present Illness (HPI):

PQRST or OLDCARTS related to the presenting problem.

Focus includes: precipitating factors

current/recent stressors

reason for seeking help now.

Pertinent history in record and from patient: X

During assessment: Patient describes their mood as X and indicated it has gotten worse in TIME.

Patient self-esteem appears fair, no reported feelings of excessive guilt, no reported anhedonia, does not report sleep disturbance, does not report change in appetite, does not report libido disturbances, does not report change in energy, no reported changes in concentration or memory.

Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. Patient does not report excessive fears, worries or panic attacks. Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a characterological nature.

SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, and denies inappropriate/illegal behaviors.

Past Medical Hx:

Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury.Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C.Surgical history no surgical history reported.

Past Psychiatric Hx:

Previous psychiatric diagnoses: none reported.

Describes course of illness if any. _____________________________

Allergies: NKDFA.(medication & food)

Social History, Family History. Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…

Safety concerns:

History of Violence to Self: none reported

History of Violence to Others: none reported

Auditory Hallucinations: none reported

Visual Hallucinations: none reported

Trauma history:

Client does not report history of trauma including abuse, domestic violence, witnessing disturbing events.

Substance Use:

Client denies use or dependence on nicotine/tobacco products. Client does not report abuse of or dependence on ETOH, and other illicit drugs.

Past Psych Med Trials:

Current Psych Medications:

Family Psychiatric Hx:

Substance use: not reported

Suicides: not reported

Psychiatric diagnoses/hospitalization: not reported

Developmental diagnoses: not reported

Others: not reported

Social History:

Occupational History: currently unemployed. Denies previous occupational hx Military service History: Denies previous military hx.

Education history: completed HS and vocational certificate

Developmental History: (Childhood History): no significant details reported

Legal History: no reported/known legal issues, no reported/known conservator or guardian.

Spiritual/Cultural Considerations: none reported.

ROS:

Constitutional: No report of fever or weight loss.

Eyes: No report of acute vision changes or eye pain.

ENT: No report of hearing changes or difficulty swallowing.

Cardiac: No report of chest pain, edema or orthopnea.

Respiratory: Denies dyspnea, cough or wheeze.

GI: No report of abdominal pain.

GU: No report of dysuria or hematuria.

Musculoskeletal: No report of joint pain or swelling.

Skin: No report of rash, lesion, abrasions.

Neurologic: No report of seizures, blackout, numbness or focal weakness. Endocrine: No report of polyuriaor polydipsia.

Hematologic: No report of blood clots or easy bleeding.

Allergy: No report of hives or allergic reaction.

Reproductive: No report of significant issues.

(females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…)

Pain:________________

Objective Data

This is where the “facts” are located. Vitals, **Physical Exam (if performed, will not be performed every visit in every setting) Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results.

Vital Signs:

Ht:_________________

Wt:_________________

BMI: _______________

BMI Range:__________

LABS:

Lab findings: WNL

Tox screen: Negative

Alcohol: Negative

HCG: N/A

Risk assessment: suicide/violence

Mental Status Examination (MSE)

a) Appearance:

b) Behavior and psychomotor activity

c) Consciousness

d) Orientation

e) Memory

f) Concentration and attention

g) Intellectual functioning

h) Speech and language

i) Perceptions

j) Thought processes

k) Thought content

l) Suicidality or homicidal

m) Mood

n) Affect

o) Judgment

p) Insight

q) Reliability

Psychiatric Review of System (Psych ROS)

a) Anxiety

b) Mania

c) Depression

d) Schizophrenia

e) Panic attacks

f) PTSD

g) OCD

h) ADHD

i) Eating disorders

j) Personality Disorders

Diagnostic testing:

PHQ-9, psychiatric assessment

Assessment

Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment.

Informed Consent Ability

Impression formulation:

DSM5 Diagnosis: with ICD-10 codes:

Differential Diagnosis:

Dx: –

Dx: –

Dx: –

Patient has the ability/capacity appears to respond to psychiatric medications/psychotherapy and appears to have the need for medications/psychotherapy and is willing to maintain adherent. Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment.

Clinical Plan

Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options and complimentary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment and include patient education.

Inpatient:

Psychiatric. Admits to X as per HPI.

Estimated stay 3-5 days

Patient is found to be very anxious and aggressive behavior.

Patient likely poses a high-risk harm to self and harm risk to others at this time. Patient has abnormal perceptions and it appear to be responding to internal stimuli.

Pharmacologic interventions / treatment:

Including dosage, route, and frequency and non-pharmacologic:

Education: including health promotion, maintenance, and psychosocial needs:

Psychoeducation

Mindfulness and Relaxation:

Importance of medication

Discussed current tobacco use. NRT indicated.

Safety planning

Discuss worsening sx and when to contact office or report to ED

> 50% time spent counseling/coordination of care.

Time spent in Psychotherapy: 18 minutes

Visit lasted: 55 minutes

Referrals:

 Psychotherapy referral for CBT

 Endocrinologist for diabetes

 Other

Follow-up:

including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit 2 weeks

References

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