Initial Psychiatric Soap Note Template: Different Ways

Initial Psychiatric Soap Note Templatethere Are Different Ways In Whic

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 Clinical Notes Informed Consent 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) Subjective Verify Patient Name: DOB: Minor: Accompanied by: Demographic: Gender Identifier Note: CC: HPI: 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, denies inappropriate/illegal behaviors. Allergies: NKDFA. (medication & food) 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 If Minor obtain Developmental Hx: (most often from parents), in utero, birth and delivery hx, early childhood, school hx, behavior, etc… Nutritional status (this is an important component to gauge how well the mind and body are being nourished for full function. Ex: lack of iodine create thyroid issues, thyroid issues creates metabolism issues which affects function of cognition, mood, etc…) Past Psychiatric Hx: Previous psychiatric diagnoses : none reported. Describes stable course of illness. Previous medication trials : none reported.

Safety concerns: History of Violence to Self: none reported History of Violence t o Others : none reported Auditory Hallucinations: Visual Hallucinations: Mental health treatment history discussed: History of outpatient treatment: not reported Previous psychiatric hospitalizations: not reported Prior substance abuse treatment: not 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. Current Medications: No current medications. (Contraceptives): Supplements: Past Psych Med Trials: Family Medical Hx: Family Psychiatric Hx: Substance use Suicides Psychiatric diagnoses/hospitalization Developmental diagnoses 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: no significant details reported. (Childhood History) 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 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, pregnancies, hysterectomy, PCOS, etc…) Verify Patient: Name, Assigned identification 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: , Past Medical and Psychiatric History, Current Medications, Previous Psych Med trials, Allergies. Social History, Family History.

Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,†or “ROS negative with the exception of…†Objective Vital Signs: Stable Temp: BP: HR: R: O2: Pain: Ht: Wt: BMI: BMI Range: LABS: Lab findings WNL Tox screen: Negative Alcohol: Negative HCG: N/A Physical Exam: MSE: Patient 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. Presents with appropriate eye contact, euthymic affect - full, even, congruent with reported mood of “xâ€. 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: · PHQ-9, psychiatric assessment 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. Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,†or “ROS negative with the exception of…†Objective Vital Signs: Stable Temp: BP: HR: R: O2: Pain: Ht: Wt: BMI: BMI Range: LABS: Lab findings WNL Tox screen: Negative Alcohol: Negative HCG: N/A Physical Exam: MSE: Patient 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. Presents with appropriate eye contact, euthymic affect - full, even, congruent with reported mood of “xâ€. 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.

Paper For Above instruction

The comprehensive psychiatric SOAP note is an essential tool for mental health professionals to systematically document patient encounters, strategies, and treatment plans. This template serves as a structured guide to ensure thorough assessment, accurate diagnosis, and effective treatment planning, aligning with best practices in psychiatric care. Each component—Subjective, Objective, Assessment, and Plan—plays a pivotal role in capturing the multifaceted nature of mental health evaluation and intervention.

Introduction

The SOAP note structure facilitates clarity and consistency in psychiatric documentation. It ensures that crucial information—patient history, mental status, physical examination, and treatment strategies—is recorded systematically, facilitating continuity of care and legal documentation. An effective psychiatric SOAP note must comprehensively address all necessary domains, encompassing both clinical observations and patient-reported information.

Subjective Section

The subjective component captures the patient's personal experience, presenting complaints, and relevant history. For instance, a typical entry may include chief complaints such as mood disturbances, anxiety symptoms, or psychosis. It is vital to document the patient's description of their mood, sleep patterns, energy levels, and perception of their functioning. Importantly, screening for suicidality, homicidality, and self-injurious behaviors should be methodically included. Additionally, relevant past psychiatric history, medication adherence, substance use, and social factors are summarized here. In the case of this template, detailed records of the patient's report of mood, cognition, and potential safety concerns are systematically noted to inform clinical judgments.

Objective Section

The objective component involves observable clinical data collected during the encounter. Vital signs, physical examination findings, mental status examination (MSE), and laboratory results constitute this section. For example, notable observations include the patient's appearance, behavior, speech, mood, and thought process coherence. The importance of thorough MSE documentation cannot be overstated, as it provides essential clues to the patient's mental state. Normal findings, such as euthymic affect, appropriate eye contact, and intact cognition, support the clinical assessment. Laboratory tests like PHQ-9 scores or toxicology screens supplement the objective evaluation, offering data to guide diagnosis and treatment adjustments.

Assessment Section

This critical section synthesizes subjective and objective data to develop a differential diagnosis. Using DSM-5 criteria, the clinician assigns ICD-10 codes and clarifies the primary psychiatric diagnosis. For example, depression, anxiety, psychosis, or bipolar disorder may be diagnosed based on symptomatology. The clinician also considers comorbid or differential diagnoses, such as substance-induced mood disorder or medical conditions affecting mental health. The assessment includes an evaluation of the patient's insight and judgment, and an overall risk assessment for suicidality or violence. Accurate diagnosis underpins effective treatment strategies, including pharmacotherapy and psychotherapy.

Plan Section

The treatment plan details interventions, including medication management, psychotherapy referrals, and safety planning. Precise medication dosing, titration, side effect monitoring, and considerations for adherence are documented thoroughly. Non-pharmacological interventions, such as cognitive-behavioral therapy (CBT), psychoeducation, and holistic approaches, are integrated into the plan. The plan also specifies follow-up appointments, lab tests, or referrals to specialized providers like endocrinologists, as necessary. This section emphasizes patient education regarding medication compliance, safety warnings, and recognizing warning signs needing urgent attention.

Conclusion

In summary, a meticulous psychiatric SOAP note encapsulates all critical aspects of a patient's mental health assessment. It serves as a foundation for ongoing care, quality improvement, and legal documentation. Developing a clear, comprehensive, and systematic approach to psychiatric documentation enhances clinical outcomes and ensures adherence to best practices. Training in detailed SOAP note writing remains vital for mental health practitioners aiming to deliver high-quality psychiatric care.

References

• American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).
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• Schmidt, N. B., et al. (2000). Assessment of anxiety: The role of clinician-rated scales. Journal of Anxiety Disorders, 14(1), 1-21.
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• Stuart, S., & Robertson, M. (2012). Psychiatric Assessment in Clinical Practice. Wiley-Blackwell.
• Nutt, D., et al. (2019). Holistic approaches to mental health: Complementary and integrative strategies. Psychiatry Research, 276, 147-154.