soap note

soap note and create a patient that has new onset of schizopherniapls follow the out line of the soap note template the other document is how the assighment will be graded 

Psychiatric SOAP Note Template

Encounter date: ________________________

Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____

Reason for Seeking Health Care: ______________________________________________

HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SI/HI: _______________________________________________________________________________

Sleep:  _________________________________________        
Appetite:  ________________________

Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________

Current perception of Health: Excellent Good Fair Poor

Psychiatric History:

Inpatient hospitalizations:

Date

Hospital

Diagnoses

Length of Stay

Outpatient psychiatric treatment:

Date

Hospital

Diagnoses

Length of Stay

Detox/Inpatient substance treatment:

Date

Hospital

Diagnoses

Length of Stay

History of suicide attempts and/or self injurious behaviors:
____________________________________

Past Medical History

· Major/Chronic Illnesses____________________________________________________

· Trauma/Injury ___________________________________________________________

· Hospitalizations __________________________________________________________

Past Surgical History___________________________________________________________

Current psychotropic medications:
 

_________________________________________ ________________________________

_________________________________________ ________________________________
_________________________________________ ________________________________

Current prescription medications:
 

_________________________________________ ________________________________
_________________________________________ ________________________________
_________________________________________ ________________________________

OTC/Nutritionals/Herbal/Complementary therapy:

_________________________________________ ________________________________
_________________________________________ ________________________________

Substance use

: (alcohol, marijuana, cocaine, caffeine, cigarettes)

Substance

Amount

Frequency

Length of Use

Family Psychiatric History: _____________________________________________________

Social History

Lives: Single family House/Condo/ with stairs: ___________
Marital Status:________

Education:____________________________

Employment Status: ______
Current/Previous occupation type: _________________

Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________

Sexual Orientation: _______ Sexual Activity: ____
Contraception Use: ____________

Family Composition: Family/Mother/Father/Alone
: _____________________________

Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________

________________________________________________________________________

Health Maintenance

Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____

Exposures:

Immunization HX:

Review of Systems:

General:

HEENT:

Neck:

Lungs:

Cardiovascular:

Breast:

GI:

Male/female genital:

GU:

Neuro:

Musculoskeletal:

Activity & Exercise:

Psychosocial:

Derm:

Nutrition:

Sleep/Rest:

LMP:

STI Hx:

Physical Exam

BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
percentile) _____

General:
HEENT:
Neck:

Pulmonary:

Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:

Misc.

Mental Status Exam

Appearance:

Behavior:

Speech:

Mood:

Affect:

Thought Content:

Thought Process:

Cognition/Intelligence:

Clinical Insight:

Clinical Judgment:

Significant Data/Contributing Dx/Labs/Misc.

Plan:

Differential Diagnoses

1.

2.

Principal Diagnoses

1.

2.

Plan

Diagnosis #1

Diagnostic Testing/Screening:

Pharmacological Treatment:

Non-Pharmacological Treatment:

Education:

Referrals:

Follow-up:

Anticipatory Guidance:

Diagnosis #2

Diagnostic Testingg/Screenin:

Pharmacological Treatment:

Non-Pharmacological Treatment:

Education:

Referrals:

Follow-up:

Anticipatory Guidance:

Signature (with appropriate credentials): __________________________________________

Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________

DEA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)______________________________ Age ___________
Date: _______________

RX ______________________________________

SIG:

Dispense: ___________
Refill: _________________

No Substitution

Signature: ____________________________________________________________

Rev. 10162021 LM

1.

Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic. Make up a patient that was depressed with anxiety

2. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.  

S = 

Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS) 

O = 

Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam, (Focused), and Mental Status Exam 

A = 

Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes 

P = 

Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up 

Psychiatric SOAP Note Rubric

Criteria

Ratings

Pts

Chief Complaint (Reason for seeking health care) – S

4 to >3 pts

Exemplary

Includes a direct quote from patient about presenting problem.

3 to >2 pts

Distinguished

Includes a direct quote from patient and other unrelated information.

2 to >0 pts

Developing

Includes information but information is NOT a direct quote.

0 pts

Novice

Information is completely missing.

/ 4 pts

Demographics – S

2 pts

Exemplary

Begins with patient initials, age, race, ethnicity, and gender (5 demographics).

1.5 pts

Distinguished

Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity, and gender).

1 pts

Developing

Begins with 3 or less patient demographics (patient initials, age, race, ethnicity, and gender).

0 pts

Novice

Information is completely missing.

/ 2 pts

History of the Present Illness (HPI) – S

5 to >3 pts

Exemplary

Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity).

3 to >2 pts

Distinguished

Includes the presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity).

2 to >1 pts

Developing

Includes the presenting problem and 4 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity).

1 to >0 pts

Novice

The presenting problem is not clearly stated and/or there are < 4 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity). / 5 pts Allergies - S 2 pts Exemplary Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy). 1.5 pts Distinguished If allergies are present, student does not list each type of drug, environmental factor, herbal, food, latex name and include severity of allergy OR description of the allergy. 1 pts Developing If allergies are present, student only lists the type of allergy and omits the name of the allergy. 0 pts Novice Information is completely missing. / 2 pts Review of Systems (ROS) - S 5 to >3 pts

Exemplary

Includes a minimum of 3 assessments for each body system, assesses at least 9 body systems directed to chief complaint, AND uses the words “admits” and “denies.”

3 to >2 pts

Distinguished

Includes 3 or fewer assessments for each body system, assesses 5-8 body systems directed to chief complaint, AND uses the words “admits” and “denies.”

2 to >0 pts

Developing

Includes 3 or fewer assessments for each body system, and assesses less than 5 body systems directed to chief complaint, OR student does not use the words “admits” and “denies.”

0 pts

Novice

Information is completely missing.

/ 5 pts

Vital Signs – O

2 pts

Exemplary

Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain).

1.5 pts

Distinguished

Includes at least 6 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain).

1 pts

Developing

Includes at least 4 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain).

0 pts

Novice

Information is completely missing.

/ 2 pts

Labs, Diagnostic Tests and Screening Tools – O

3 pts

Exemplary

During the visit: Includes a list of the labs, diagnostic tests or screening tools reviewed at the visit, values of lab results or screening tools, and highlights abnormal values, OR acknowledges no labs/diagnostic tests were reviewed.

2 pts

Distinguished

During the visit: Includes a list of the labs, diagnostic tests, or screening tools reviewed at the visit, but does not include the values of lab results or screening tools, but does not highlight abnormal values.

1 pts

Developing

During the visit: Includes a list of the labs, diagnostic tests, or screening tools reviewed at the visit but does not include the values of the results or highlight abnormal values.

0 pts

Novice

Information is completely missing.

/ 3 pts

Medications-S

3 pts

Exemplary

Includes a list of all of the patient reported psychiatric and medical medications and the diagnosis for the medication (including name, dose, route, frequency).

2 pts

Distinguished

Includes a list of all of the patient reported psychiatric and but omits the medical medications and the diagnosis for the medication (including name, dose, route, frequency).

1 pts

Developing

Includes a list of some of the patient reported psychiatric and/or medical medications and the diagnosis for the medication (omits the dose, route, frequency of the medications).

0 pts

Novice

Information is completely missing.

/ 3 pts

Past Medical History-S

3 pts

Exemplary

Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current.

2 pts

Distinguished

Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current.

1 pts

Developing

Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current.

0 pts

Novice

Information is completely missing.

/ 3 pts

Past Psychiatric History-S

4 to >3 pts

Exemplary

Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), and year of diagnosis.

3 to >2 pts

Distinguished

Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (omits addiction treatment), and year of diagnosis.

2 to >0 pts

Developing

Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), and does not include the year of diagnosis.

0 pts

Novice

The information is completely missing.

/ 4 pts

Family Psychiatric History-S

4 to >3 pts

Exemplary

Includes an assessment of at least 6 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder, and history of suicidal attempts.

3 to >2 pts

Distinguished

Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder, and history of suicidal attempts.

2 to >0 pts

Developing

Includes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder, and history of suicidal attempts.

0 pts

Novice

Information is completely missing.

/ 4 pts

Social History-S

3 pts

Exemplary

Distinguished Includes all 11 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation.

2 pts

Distinguished

Includes at least 8 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation.

1 pts

Developing

Includes all 6 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation.

0 pts

Novice

Information is completely missing.

/ 3 pts

Mental Status Exam-O

15 to >12 pts

Exemplary

Includes all 10 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with detailed descriptions for each area.

12 to >10 pts

Distinguished

Includes all 8 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with detailed descriptions for each area.

10 to >0 pts

Developing

Includes >6 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with some descriptions for each area.

0 pts

Novice

Includes <3 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) OR detailed descriptions is not included for each area. / 15 pts Primary Diagnoses-A 11 to >6 pts

Exemplary

Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority) using the DSM-5-TR. The correct ICD-10 billing code is used.

6 to >3 pts

Distinguished

Includes a clear outline of the accurate diagnoses addressed at the visit but does not list the diagnoses in descending order of priority using the DSM-5-TR. The correct ICD-10 billing code is used.

3 to >0 pts

Developing

Includes an inaccurate diagnosis as the principal diagnosis. The ICD-10 code is incorrect or missing.

0 pts

Novice

Information is completely missing.

/ 11 pts

Differential Diagnoses-A

3 pts

Exemplary

Includes at least 2 differential diagnoses that can be supported by the subjective and objective data provided using the DSM-5-TR. The correct ICD-10 billing code is used.

2 pts

Distinguished

Includes 1 differential diagnosis that can be supported by the subjective and objective data provided using the DSM-5-TR. The correct ICD-10 billing code is used.

1 pts

Developing

Includes at least 1 differential diagnosis that is NOT supported by the subjective and objective data. The ICD-10 code is incorrect or missing.

0 pts

Novice

Information is completely missing.

/ 3 pts

Outcome Labs/Screening Tools – O

3 pts

Exemplary

After the visit: orders appropriate diagnostic/lab testing or screening tool 100% of the time OR acknowledges “no diagnostic testing or screening tool clinically required at this time.”

2 pts

Distinguished

After the visit: orders appropriate diagnostic/lab testing 50% of the time OR acknowledges “no diagnostic testing or screening tool clinically required at this time.”

1 pts

Developing

After the visit, orders appropriate diagnostic testing less than 50% of the time.

0 pts

Novice

Information is completely missing.

/ 3 pts

Treatment

10 to >8 pts

Exemplary

Includes a detailed pharmacologic and non pharmacological treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the following: drug/vitamin/herbal name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. For non-pharmacological treatment, includes: treatment name, frequency, duration. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. The plan is supported by the current US clinical guidelines.

8 to >6 pts

Distinguished

Includes a detailed pharmacologic and non pharmacological treatment plan for each of the diagnoses listed under “assessment”. The plan includes 4-7 of the following: drug/vitamin/herbal name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. For non-pharmacological treatment, includes: treatment name, frequency, duration. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. The plan is supported by the current US clinical guidelines.

6 to >0 pts

Developing

Includes a detailed pharmacologic and non pharmacological treatment plan for each of the diagnoses listed under “assessment”. The plan includes 4 of the following: drug/vitamin/herbal name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. Non-pharmacological treatment NOT included. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. The plan is NOT supported by the current US clinical guidelines OR is unsafe.

0 pts

Novice

Information is completely missing.

/ 10 pts

Patient/Family Education-P

5 to >3 pts

Exemplary

Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives.

3 to >2 pts

Distinguished

Includes at least 2 strategies to promote and develop skills for managing their illness and at least 2 self-management methods on how to incorporate healthy behaviors into their lives.

2 to >0 pts

Developing

Includes at least 1 strategies to promote and develop skills for managing their illness and at least 1 self-management methods on how to incorporate healthy behaviors into their lives.

0 pts

Novice

Information is completely missing.

/ 5 pts

Referral

3 pts

Exemplary

Provides a detailed list of medical and other interdisciplinary referrals or documents NO REFERRAL ADVISED AT THIS TIME. Includes a timeline for follow up appointments.

2 pts

Distinguished

Provides a medical or other interdisciplinary referral or documents NO REFERRAL ADVISED AT THIS TIME. Includes a timeline for follow up appointments.

1 pts

Developing

Provides a medical or other interdisciplinary referral. DOES NOT include a timeline for follow up appointments.

0 pts

Novice

Information is completely missing.

/ 3 pts

APA Formatting

5 to >3 pts

Exemplary

Effectively uses literature and other resources to inform their work. Exceptional use of citations and extended referencing. High level of precision with APA 7th Edition writing style.

3 to >2 pts

Distinguished

Effectively uses literature and other resources to inform their work. Moderate use of citations and extended referencing. Moderate level of precision with APA 7th Edition writing style.

2 to >0 pts

Developing

Ineffectively uses literature and other resources to inform their work. Moderate use of citations and extended referencing. APA 7th Edition writing style not strictly adhered to.

0 pts

Novice

APA style and writing mechanics not used.

/ 5 pts

References

5 to >3 pts

Exemplary

The reference page contains at least the required current scholarly academic reference and text reference. Follows APA guidelines of components: double space, 12 pt. font, abstract, level headings, hanging indent and in-text citations.

3 to >2 pts

Distinguished

References page contains one current scholarly academic resource and text reference. Follows most APA guidelines of components: double space, 12 pt. font, abstract, level headings, hanging indent, and in-text citations.

2 to >0 pts

Developing

References page contains one current or outdated scholarly academic resource. Many errors of APA guidelines: double space, 12 pt. font, abstract, level headings, hanging indent, and in-text citations.

0 pts

Novice

References page contains no current scholarly academic resources, only internet webpages or no reference page. Lack of APA guidelines for references provided or in-text citations.

/ 5 pts