Please do 4 Psych Soap notes. Template and example is provided
Psychiatric SOAP Note Template
SOAP Note No: 1
Student Name: __________________________________________
Criteria
Informed Consent
Subjective Data
Clinical Notes
Informed consent was given to the patient about the psychiatric
interview process and psychiatric/psychotherapy treatment. Verbal and
Written consent were obtained.
Please select one choice from the below statement:
___ Patient has the ability/capacity to respond and appears to
understand the risks, 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 risks, benefits, and (Will review additional consent
during treatment plan discussion)
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.
Impression formulation:
DSM5 Diagnosis: with ICD-10 codes:
Differential Diagnosis:
Dx: Dx: Dx: –
Informed Consent Ability
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
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:
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.
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
1.
2.
3.
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Criterion
Client
identifying
information.
5 points
Chief Complaint
5 points
History of
Present Illness
5 points
Typhon Soap Note Rubric
Description
Subjective
age, marital status,
general appearance, reliability, ethnicity
(state at end of scenario, in case
formulation).
“in patient’s own words” reason for visitrestate in case formulation.
e.g. R presents in this initial outpatient
appointment alone, for evaluation and
management of:
(insomnia).
(Why present now/precipitants/stressors?
When it started? How long it lasts/frequency?
What is it like? Impact on life)
Neurovegetative Symptoms:
Sleep
Appetite and weight
Energy
Concentration
Anhedonia
Mood
Diurnal variation of mood
SI/HI
Anxiety-all disorders
Mania
Psychosis
Sexual interest/performance
Must
include chronological timeline of development
of current problem, what they have tried to h
elp the problem,
assessment of strengths and usual coping stra
tegies. Include any medications tried with resp
onses.
Risk assessment: Ask about any homicidal ideation –
suicide/violence and first experience of suicidal ideation,
Present
Not Present
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5 points
Psychiatric
History
5 points
Substance Use
History
5 points
Past Medical
History:
5 points
Family History:
5 points
Personal History
5 points
and any history of attempts. Assess if ever had
feelings of hopelessness
Ask at what age first saw a counselor or psychi
atrist.
Ask about first time taking
psychotropic medications, and obtain chronol
ogical history with medications, duration and r
esponse – helpful or side
effects, with reason for discontinuation.
This section contains any history or current
use of caffeine, nicotine, illicit substance
(including marijuana), and alcohol. Include the
daily amount of use and last known use.
Include type of use such as inhales, snorts, IV,
etc. Include any histories of withdrawal
complications from tremors, Delirium
Tremens, or seizures.
For reporting
substance use, include age of first use, date of
last use, frequency, amount and method.
of use
Does patient obtain primary care?
Date/name of provider and last visit.
List any chronic illness.
with date of dx and treatment regimen.
Allergies.
Current medications.
Inquire about family history of any psychiatric
problems – depression, anxiety, substance use
disorders, psychiatric hospitalizations, suicide
attempts.
Prompt to inquire about parents, grandparent
s, aunts or uncles,
siblings and their children if applicable.
Place of birth:
As a child: (family structure, parents’
occupations, relationship with parents,
siblings, friends, abuse)
As a teen: (friends, relationships, school,
activities, sex, trouble, relationship with
parents)
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Psychosocial
5 points
Education
5 points
Employment:
5 points
Developmental
5 points
Psychiatric
Review of
Systems:
5 points
As an adult: (work, finances, education,
relationships, family, goals for future, trends
in functioning)
History: Inquire about religion/spiritual beliefs
, sexuality, living situation, education, employ
ment.
history of incarceration, current support syste
ms, hobbies, activities of interest, talents
No formal education
Elementary school completed.
Some high school-did not graduate.
High school graduate
College graduate
Unemployed
Employed
on Disability
History: Inquire about mother’s pregnancy an
d delivery, childhood with attainment of miles
tones, any
learning disabilities or academic problems.
Has patient ever experienced depression, anxi
ety, mania, ADHD, OCD, eating
disorder, psychosis, trauma, personality disord
er ?
Medical Review of Systems:
especially history of seizure or head trauma
Objective
Mental Status
Examination:
5 Points
Appearance
Behavior
Speech
Mood(inquired)
Affect (observed)
Thought process (observed)
Thought content (inquired)
Cognition (inquired – include memory/ recall)
Insight/Judgment (Some areas
are observed, and some are inquired –
describe all areas observed in Case Formulati
on)
Assets/strengths
Liabilities
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Impression
formulation
5 Points
Diagnosis
10 Points
Plan
10 Points
Do full MMSE if memory concerns or over age
65 (score 1-30)
Assessment
e.g. The patient is a 36-year-old Caucasian
male with a long history of depression and
attention deficits. Hyperactivity criteria are
essentially absent. Although medications
have been somewhat efficacious, he has
residual symptoms that are quite
troublesome
Diagnoses
Medical diagnoses
Differential diagnoses: (generally is the
medical causes of the symptoms, such as
hypothyroidism or brain tumor, for example)
Rule out diagnoses: (generally refers to DSM 5
diagnoses that you suspect and will continue
to evaluate for; e.g. if someone has MDD,
then one R/O is Bipolar II Disorder, Most
Recent Episode Depressed)
DSM-5 criteria: (what criteria are met, what
criteria are not met at this time; how arrived
at decision re the diagnosis)
Plan
Labs/ Diagnostic Tests/ Screening Tools
Medications
Dosage & directions
Why this med?
Neurochemistry & MOA
Side effects
Expected benefits
Contraindications
Black Box Warnings
Therapy prescription
Type(s), duration, etc
Why this therapy?
Expected benefits
Therapy goals
Teaching plan
Safety plan
Diet and exercise
Sleep
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Stress management/set goals/
homework
Health promotion
Relationship issues
Resources (bibliotherapy, websites,
etc)Teach about meds, side effects, caution
Other
Referrals and consultations
PCP for physical exam or other follow up for
symptoms
Psychoneurological assessment (eg. child with
learning disorder)
Outpatient substance abuse treatment, etc
Inpatient hospitalization
Follow up
Time frame for next appointment based on
assessment, safety