Psychiatric SOAP Note exchange PDF

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INITIAL PSYCHIATRIC SOAP NOTE

Initial Psychiatric SOAP Note

Initial Psychiatric SOAP Note

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INITIAL PSYCHIATRIC SOAP NOTE

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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

Clinical Notes Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient the ability/capacity to respond and appears to

Subjective Verify Patient: Name,

the risk,

benefits, and (Will review additional consent during treatment plan discussion) Verify Patient Name: Mrs. Ada Mays

Assigned identificatio DOB: 6/11/1975 n number (e.g., Minor: medical record Accompanied by:N/A number), Date of Gender Identifier Note: Female birth, Phone number, Demographic: Asian Social security Gender Identifier Note: Female number, Address, CC: Feeling sad, guilt, anxiety, emotionally down, head and stomach aches. “I feel I need Photo. help” HPI: Current feelings started 8months ago after a job loss. Include

Pertinent history in record and from patient: History of caesarian section due to child birth

demographics, chief During assessment: Patient describes their mood as anxious but optimistic complaint, subjective information from the patient, names and

The patient has a low self-esteem, countenance is flat, reports feeling sad because she has put in many applications for a job and is not getting any. She feels guilty because her husband is the

INITIAL PSYCHIATRIC SOAP NOTE

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relations of others

only one providing for the family and she is not able to do so. She feels anxious because her

present in the

husband has diabetes and is worried he might get sick one day and not be able to work to bring

interview.

in an income which may lead to they losing their home. She feels emotionally down because she feels she is the only unlucky person among their extended family without a job. She has

HPI:

headaches due to the anxiety and she is unable to sleep well at night. Most times stays awake at night unable to sleep, she experiences stomach ache because she is unable to eat and hydrate well.

Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. Patient does not report excessive fears, or panic attacks. , Past Medical and

Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity

Psychiatric History,

level, attention and concentration were observed to be within normal limits. Patient does not

Current Medications,

report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not

Previous Psych Med

report symptoms of a characterological nature.

trials,

SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation,

Allergies.

denies violent behavior, and denies inappropriate/illegal behaviors.

Social History,

Allergies: NKFDA

Family History.

(medication & food)

Review of Systems

Past Medical Hx:

(ROS) – if ROS is

Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including

negative, “ROS

history head injury.

noncontributory,” or

Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C.

“ROS negative with

Surgical history: Caesarian section in 2005 and 2009 due to child birth.

INITIAL PSYCHIATRIC SOAP NOTE the exception of…”

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Past Psychiatric Hx Previous psychiatric diagnoses: None reported Previous medication trials: none reported. Safety concerns: History of Violence to Self: none reported History of Violence to Others: none reported Auditory Hallucinations: reported. Visual Hallucinations: none reported Mental health treatment history discussed: History of outpatient treatment: None Previous psychiatric hospitalizations: not reported Prior substance abuse treatment: not reported Trauma history: Client reports Dad died in a car crash at age 7. Substance Use: Client denies use or dependence on nicotine/tobacco products. Client does not report abuse of or dependence on prescription or recreational drugs. Current Medications: (Contraceptives): N/A Supplements: Woman’s once a day vitamin Past Psych Med Trials: None Family Medical Hx: Mother diagnosed with depression and anxiety. Family Psychiatric Hx: Substance use: None reported. Suicides: none reported.

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Psychiatric diagnoses/hospitalization: none reported. Developmental diagnoses: none reported. Social History: Occupational History: currently unemployed. Lost job 8months ago Military service History: Denies previous military history Education history: completed high school, has college degree and has a certificate in management. Developmental History: normal childhood. (Childhood History) Legal History: none reported. Spiritual/Cultural Considerations: Seventh Day Adventist. 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 polyuria or polydipsia.

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Hematologic: No report of blood clots or easy bleeding. Allergy: No report of hives or allergic reaction.

Objective This is where the

Reproductive: Timely mensuration Vital Signs: Stable Temp: 98.2oF

“facts” are located. BP: 122/80 mmHg Vitals, HR: 72 beats per minute **Physical Exam (if R:18 breaths per minute performed, will not be O2: 99 mmHg performed every visit Pain: not reported. in every setting) Ht: 5’7” Include relevant labs, Wt:155lbs test results, and BMI: 23 Include MSE, risk BMI Range: 18.5-24.9 is considered normal assessment here, and LABS: psychiatric screening Lab findings: No labs drawn measure results. Tox screen: Alcohol: HCG:

Physical Exam: MSE: Patient is cooperative and conversant, appears without acute distress, and fully oriented x 4.

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Patient is dressed appropriately for age and season. Psychomotor activity appears within normal. Presents with appropriate eye contact, euthymic affect - flat, congruent with reported mood of feeling nervous. Speech: spontaneous, normal rate, appropriate volume/tone with no problems expressing self. TC: no abnormal content elicited, denies suicidal ideation and denies homicidal ideation. Process appears linear, coherent, goal-directed. Cognition appears grossly intact with appropriate attention span & concentration and average fund of knowledge. Judgment appears fair. Insight appears fair 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 Diagnostic testing: GAD-7 a diagnostic test=18 The result of the GAD-7 shows a score of 18, which is greater than 10, informing that the patient has GAD. Scoring 18 means the patient has severe anxiety levels. (Spitzer, 2017).

Assessment Include your findings,

DSM5 Diagnosis: with ICD-10 codes Dx: -

296.31 Moderate Recurrent Major depressive disorder/F33.1

Dx: -

300.02 Generalized anxiety disorder/F41.1

diagnosis and differentials (DSM-5 Dx:-307.42 Persistent disorder of initiating or maintaining sleep/F51.12 and any other medical Patient has the ability/capacity appears to respond to psychiatric medications/psychotherapy

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diagnosis) along with

and appears to understand the need for medications/psychotherapy and is willing to maintain

ICD-10 codes,

adherent.

treatment options, and

Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining

patient input

treatment.

regarding treatment

CBT with talk therapy recommended for patient. Provided with list of providers to choose from

options (if possible),

and given educational resources to assist with her depression and anxiety.

including obstacles to treatment.

Informed Consent Ability

Plan 296.31: Mrs. Mays will be a part of a weekly therapy session. She will also attend a weekly Cognitive Behavioral Therapy session to address her anxiety and depressive disorder. “Cognitive

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behavioral therapy (CBT) is one of the most evidence-based psychological interventions for the treatment of several psychiatric disorders such as depression, anxiety disorders, somatoform disorder, and substance use disorder”. Treatment guidelines for depression and anxiety suggest that CBT interventions are effective and acceptable strategy for treatment.(Gautam et al, 2020) Plan 300.02: Mrs May will continue use of weekly CBT for treatment of the anxiety disorder. As previously mentioned CBT is therapeutic for patients experiencing depression based on evidence-based practice. Plan 307.42: Treatment for patient’s sleep disorder will also be addressed in her weekly CBT sessions. “Cognitive Behavioral Therapy for Insomnia (CBTI) comprises of a specific set of techniques that strengthen the bed-sleep connection, realign the homeostatic mechanisms and the circadian rhythm and decrease anxiety and rumination about sleep”(Anderson, 2018). Medication regimen for the treatment of depression, anxiety and insomnia were discussed with patient. Patient chose to use of several weeks of CBT treatment for her conditions before committing to use of medications.

Plan Include a specific

. Referrals: Anxiety Treatment Center for assistance with anxiety Follow-up including return to clinic (RTC) with time frame of 2weeks

plan, including The patient is instructed to attend follow-up after two weeks to assess the effectiveness CBT in medications & dosing reducing depression, GAD and insomnia symptoms. & titration ☒ > 50% time spent counseling/coordination of care.

INITIAL PSYCHIATRIC SOAP NOTE considerations, lab

Time spent in Psychotherapy 50 minutes

work ordered,

Visit lasted 60 minutes

referrals to

Billing Codes for visit:

psychiatric and

Psychiatric diagnostic evaluation with medical services 90792.

medical providers,

Evaluation and management with 30 minutes psychotherapy 90833.

therapy

Brief emotional/behavioral assessment 96127 (APA, n.d).

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.

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INITIAL PSYCHIATRIC SOAP NOTE

References Anderson, K. N. (2018, January). Insomnia and cognitive behavioural therapy-how to assess your patient and why it should be a standard part of care. Journal of thoracic disease. Retrieved September 20, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5803038/.

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Deborah R. Glasofer, P. D. (n.d.). How is generalized anxiety disorder diagnosed using the DSM5? Verywell Mind. Retrieved September 19, 2021, from https://www.verywellmind.com/dsm-5-criteria-for-generalized-anxiety-disorder-1393147. Gad-7 (general anxiety disorder-7). MDCalc. (n.d.). Retrieved September 19, 2021, from https://www.mdcalc.com/gad-7-general-anxiety-disorder-7. Gautam, M., Tripathi, A., Deshmukh, D., & Gaur, M. (2020, January). Cognitive behavioral therapy for Depression. Indian journal of psychiatry. Retrieved September 20, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7001356/. Spitzer, S. L. (2017). Diagnostic and statistical manual of mental disorders: Dsm-5. CBS Publishers & Distributors, Pvt. Ltd....