Initial Psychiatric SOAP Note Template<\/p>\n
There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to develop your style of SOAP in the psychiatric practice setting.<\/p>\n
Criteria\tClinical Notes<\/p>\n
Informed Consent\tInformed consent given to patient about psychiatric interview process and psychiatric\/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability\/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion)<\/p>\n
Subjective\tVerify Patient
\nName:
\nDOB:<\/p>\n
Minor:
\nAccompanied by:<\/p>\n
Demographic:<\/p>\n
Gender Identifier Note:<\/p>\n
CC:<\/p>\n
HPI:<\/p>\n
Pertinent history in record and from patient: X<\/p>\n
During assessment: Patient describes their mood as X and indicated it has gotten worse in TIME.<\/p>\n
Patient self-esteem appears fair, no reported feelings of excessive guilt,
\nno reported anhedonia, does not report sleep disturbance, does not report change in appetite, does not report libido disturbances, does not report change in energy,
\nno reported changes in concentration or memory.<\/p>\n
Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. Patient does not report excessive fears, worries or panic attacks.
\nPatient does not report hallucinations, delusions, obsessions or compulsions. Patient\u2019s 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.<\/p>\n
SI\/ HI\/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate\/illegal behaviors.<\/p>\n
Allergies: NKDFA.
\n(medication & food)<\/p>\n
Past Medical Hx:
\nMedical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury.
\nPatient denies history of chronic infection, including MRSA, TB, HIV and Hep C.
\nSurgical history no surgical history reported<\/p>\n
Past Psychiatric Hx:
\nPrevious psychiatric diagnoses: none reported.
\nDescribes stable course of illness.
\nPrevious medication trials: none reported.<\/p>\n
Safety concerns:
\nHistory of Violence to Self: none reported
\nHistory of Violence to Others: none reported
\nAuditory Hallucinations:
\nVisual Hallucinations:<\/p>\n
Mental health treatment history discussed:
\nHistory of outpatient treatment: not reported
\nPrevious psychiatric hospitalizations: not reported
\nPrior substance abuse treatment: not reported<\/p>\n
Trauma history: Client does not report history of trauma including abuse, domestic violence, witnessing disturbing events.<\/p>\n
Substance Use: Client denies use or dependence on nicotine\/tobacco products.
\nClient does not report abuse of or dependence on ETOH, and other illicit drugs.<\/p>\n
Current Medications: No current medications.
\n(Contraceptives):
\nSupplements:<\/p>\n
Past Psych Med Trials:<\/p>\n
Family Medical Hx:<\/p>\n
Family Psychiatric Hx:
\nSubstance use
\nSuicides
\nPsychiatric diagnoses\/hospitalization
\nDevelopmental diagnoses<\/p>\n
Social History:
\nOccupational History: currently unemployed. Denies previous occupational hx
\nMilitary service History: Denies previous military hx.
\nEducation history: completed HS and vocational certificate
\nDevelopmental History: no significant details reported.
\n(Childhood History)
\nLegal History: no reported\/known legal issues, no reported\/known conservator or guardian.
\nSpiritual\/Cultural Considerations: none reported.<\/p>\n
ROS:
\nConstitutional: No report of fever or weight loss.
\nEyes: No report of acute vision changes or eye pain.
\nENT: No report of hearing changes or difficulty swallowing.
\nCardiac: No report of chest pain, edema or orthopnea.
\nRespiratory: Denies dyspnea, cough or wheeze.
\nGI: No report of abdominal pain.
\nGU: No report of dysuria or hematuria.
\nMusculoskeletal: No report of joint pain or swelling.
\nSkin: No report of rash, lesion, abrasions.
\nNeurologic: No report of seizures, blackout, numbness or focal weakness. Endocrine: No report of polyuria or polydipsia.
\nHematologic: No report of blood clots or easy bleeding.
\nAllergy: No report of hives or allergic reaction.
\nReproductive: No report of significant issues. (females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc\u2026)<\/p>\n
Verify Patient: Name, Assigned identification number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo.<\/p>\n
Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview.<\/p>\n
HPI:<\/p>\n
, Past Medical and Psychiatric History,
\nCurrent Medications, Previous Psych Med trials,
\nAllergies.
\nSocial History, Family History.
\nReview of Systems (ROS) \u2013 if ROS is negative, \u201cROS noncontributory,\u201d or \u201cROS negative with the exception of\u2026\u201d
\nObjective\t\tVital Signs: Stable
\nTemp:
\nBP:
\nHR:
\nR:
\nO2:
\nPain:
\nHt:
\nWt:
\nBMI:
\nBMI Range:<\/p>\n
LABS:
\nLab findings WNL
\nTox screen: Negative
\nAlcohol: Negative
\nHCG: N\/A<\/p>\n
Physical Exam:
\nMSE:
\nPatient is cooperative and conversant, appears without acute distress, and fully oriented x 4. Patient is dressed appropriately for age and season. Psychomotor activity appears within normal.
\nPresents with appropriate eye contact, euthymic affect – full, even, congruent with reported mood of \u201cx\u201d. Speech: spontaneous, normal rate, appropriate volume\/tone with no problems expressing self.
\nTC: no abnormal content elicited, denies suicidal ideation and denies homicidal ideation. Process appears linear, coherent, goal-directed.
\nCognition appears grossly intact with appropriate attention span & concentration and average fund of knowledge.
\nJudgment appears fair . Insight appears fair<\/p>\n
The patient is able to articulate needs, is motivated for compliance and adherence to medication regimen. Patient is willing and able to participate with treatment, disposition, and discharge planning.<\/p>\n
This is where the \u201cfacts\u201d are located.
\nVitals,
\n**Physical Exam (if performed, will not be performed every visit in every setting)
\nInclude relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results.
\nAssessment\tDSM5 Diagnosis: with ICD-10 codes<\/p>\n
Dx: –
\nDx: –
\nDx: –<\/p>\n
Patient has the ability\/capacity appears to respond to psychiatric medications\/psychotherapy and appears to understand the need for medications\/psychotherapy and is willing to maintain adherent.
\nReviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment.
\nInclude 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.<\/p>\n
Informed Consent Ability
\nPlan<\/p>\n
(Note some items may only be applicable in the inpatient environment)<\/p>\n
Inpatient:
\nPsychiatric. Admits to X as per HPI.
\nEstimated stay 3-5 days<\/p>\n
Safety Risk\/Plan: Patient is found to be stable and has control of behavior. Patient likely poses a minimal risk to self and a minimal risk to others at this time.
\nPatient denies abnormal perceptions and does not appear to be responding to internal stimuli.<\/p>\n
Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic:<\/p>\n
\u2022\tNo changes to current medication, as listed in chart, at this time
\n\u2022\tor\u2026Zoloft is an excellent option for many women who experience any menstrual cycle complaints. I usually start at 50 mg and move to 100 week 6-8. f\/u within 2 weeks initially then every 6-8 weeks.
\n\u2022\tPsychotherapy referral for CBT
\nEducation, including health promotion, maintenance, and psychosocial needs
\n\u2022\tImportance of medication
\n\u2022\tAssignment help – Discussed current tobacco use. NRT not indicated.
\n\u2022\tSafety planning
\n\u2022\tAssignment help – Discuss worsening sx and when to contact office or report to ED
\nReferrals: endocrinologist for diabetes
\nFollow-up, including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit 2 weeks<\/p>\n
\u2612 > 50% time spent counseling\/coordination of care.<\/p>\n
Time spent in Psychotherapy 18 minutes<\/p>\n
Visit lasted 55 minutes<\/p>\n
Billing Codes for visit:
\nXX
\nXX
\nXX<\/p>\n
____________________________________________
\nNAME, TITLE<\/p>\n
Date: Click here to enter a date. Time: X<\/p>\n
——-<\/p>\n
Template for a Psychiatric SOAP Note<\/p>\n
A Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note can be completed in a variety of ways. This is a template to help you as you continue to refine your SOAP style in the psychiatric practice context.<\/p>\n
Clinical Notes Criteria<\/p>\n
Consent Based on Information<\/p>\n
The patient receives informed permission regarding the psychiatric interview process and psychiatric\/psychotherapy treatment. Consent was obtained both verbally and in writing. The patient has the ability to respond and appears to be aware of the risks, advantages, and alternatives (Will review additional consent during treatment plan discussion)<\/p>\n
Patient’s Subjective Verification<\/p>\n
Name:<\/p>\n
DOB:<\/p>\n
Minor:<\/p>\n
Accompanied by:<\/p>\n
Demographic:<\/p>\n
Gender Identifier Note:<\/p>\n
CC:<\/p>\n
HPI:<\/p>\n
Pertinent history in record and from patient: X<\/p>\n
During assessment: Patient describes their mood as X and indicated it has gotten<\/p>\n","protected":false},"excerpt":{"rendered":"
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