Science Question

Initial Psychiatric SOAP Note Template
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.
Criteria
Informed Consent
Subjective
Verify Patient: Name,
Assigned identificatio
n number (e.g.,
medical record
number), Date of
birth, Phone number,
Social security
number, Address,
Photo.
Include demographics,
chief complaint,
subjective information
from the patient,
names and relations of
others present in the
interview.
HPI:
Clinical Notes
Informed 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)
Verify Patient
Name: Ruth
DOB:01/26/2010
Minor:
Accompanied by: Mother
Demographic:
Gender Identifier Note: Female
CC: “I was thinking about cutting my throat with a knife.”
HPI: The patient has been having suicidal thoughts few weeks ago after she began taking
Accutane for her acne. The patient was at the shopping center with mother and reported she was
having thoughts of cutting her throat with a knife.
Pertinent history in record and from patient: She stated taking Accutane months ago. She began
having suicidal thoughts recently in August. She denied ever having suicidal ideations prior to
August. Since then, she has been isolating herself, experience low mood, having voices in her
head telling her to cut her throat. She also experienced some anxiety; she began attending
virtual therapy sessions in August after the suicidal thoughts began.
During assessment: Patient describes their mood as depressed.
, Past Medical and
Psychiatric History,
Current Medications,
Previous Psych Med
trials,
Allergies.
Social History,
Family History.
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Patient self-esteem appears Patient general appearance well groomed, denies sleep issue, no
change in appetite reported.
Patient denies agitation, risk- taking behaviors, pressured speech. Patient reported being
anxious. She endorsed auditory hallucinations, denied visual, tactile hallucinations. Patient’s
activity level, attention and concentration were within normal limits. Patient denied symptoms
of eating disorder. No recent weight loss or gain noted.
Review of Systems
(ROS) – if ROS is
negative, “ROS
noncontributory,” or
“ROS negative with
the exception of…”
SI/ HI/ : Patient currently denies suicidal ideation,
Allergies: NKDFA
(medication & food)
denies homicidal ideation.
Past Medical Hx:
Medical history: Denied.
Surgical history : Denied.
Past Psychiatric Hx: none
Previous psychiatric diagnoses: none reported.
Describes stable course of illness.
Previous medication trials: none reported.
Safety concerns:
History of Violence to Self: denies
History of Violence to Others denies
Auditory Hallucinations: Voices telling her to cut her throat.
Visual Hallucinations: denies
Mental health treatment history discussed:
History of outpatient treatment: attending virtual therapy sessions.
Previous psychiatric hospitalizations: denies
Prior substance abuse treatment denies
Trauma history: patient denies abuse/ neglect
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.
Current Medication: Accutane
(Contraceptives):
Supplements:
Past Psych Med Trials: none
Family Medical Hx: none
Family Psychiatric Hx: Maternal aunt has bipolar disorder
Substance use: none
Suicides: none
Psychiatric diagnoses/hospitalization: bipolar disorder
Developmental diagnoses: none
Social History:
Occupational History: student
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Military service History: Denies previous military hx.
Education history: currently in 7th grade.
ROS:
Constitutional: denies weight loss.
Eyes: denies eyes problem.
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 polyuria or 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)
Objective
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: all within normal limit
Temp:
BP:120/61
HR:80
R:18
O2:100%
Pain: 0 out of 10
Ht:5.2
Wt:120
BMI: 21. 95
BMI Range:18.5 and 24.9
LABS:
Lab findings WNL
Tox screen: Negative
Alcohol: Negative
HCG: N/A
Physical Exam:
MSE: patient general appearance: well- groomed, psychomotor activity decreased,
speech/language: coherent. Attitude/Behavior: Guarded, mood: depressed, affect blunted.
Patient is alert and oriented to person, place, time, and situation. Thought content within normal
limit for age. Risk factors: she has been struggling with suicidal thoughts. Thought processes:
logical and linear. The patient denied having any current suicidal thoughts.
Concentration/Attention span: Concrete, recent memory: intact, remote memory: intact.
Intelligence: Average, judgment: fair, insight: fair.
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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
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.
DSM5 Diagnosis: with ICD-10 codes
Dx: Major depressive disorder with psychosis F33.2
Dx: Generalized anxiety disorder F41.1
Admit the patient to the unit, treat patient medical needs.
Inpatient:
Psychiatric. Need for further stabilization as per HPI.
Estimated stay 3-7 days
Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic:
•
Zoloft 25 mg po QAM, Abilify 5mg po QHS and group therapy.
Education, including health promotion, maintenance, and psychosocial needs
•
Take medications as directed, thirty days supplied given upon discharge.
•
Follow up with outpatient psychiatrist and therapist upon discharge.
•
Discuss worsening sx and when to contact office or report to ED
☒ > 50% time spent counseling/coordination of care.
Time spent in Psychotherapy 20 minutes
Visit lasted 60 minutes
Billing Codes for visit:
23
36
42
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____________________________________________
Edwige Fandio Ngankou, Student nurse practitioner
Date: 9/24/2022
NW_11/1/20
Time: 0800