22 Soap notes rubric and sample attached
Florida National University
PMHNP PGC
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Typhon Soap Note Rubric |
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Criterion |
Description |
Present |
Not Present |
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Subjective |
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Client identifying information. 5 points
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age, marital status, general appearance, reliability, ethnicity (state at end of scenario, in case formulation).
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Chief Complaint 5 points
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“in patient’s own words” reason for visit-restate in case formulation. e.g. R presents in this initial outpatient appointment alone, for evaluation and management of: (insomnia).
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History of Present Illness 5 points
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(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 help the problem, assessment of strengths and usual coping strategies. Include any medications tried with responses. |
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Risk assessment: suicide/violence 5 points
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Ask about any homicidal ideation – and first experience of suicidal ideation, and any history of attempts. Assess if ever had feelings of hopelessness |
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Psychiatric History 5 points
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Ask at what age first saw a counselor or psychiatrist. Ask about first time taking psychotropic medications, and obtain chronological history with medications, duration and response – helpful or side effects, with reason for discontinuation.
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Substance Use History 5 points
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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 |
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Past Medical History: 5 points
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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. |
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Family History: 5 points
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Inquire about family history of any psychiatric problems – depression, anxiety, substance use disorders, psychiatric hospitalizations, suicide attempts. Prompt to inquire about parents, grandparents, aunts or uncles, siblings and their children if applicable.
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Personal History 5 points
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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) As an adult: (work, finances, education, relationships, family, goals for future, trends in functioning) |
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Psychosocial 5 points
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History: Inquire about religion/spiritual beliefs, sexuality, living situation, education, employment. history of incarceration, current support systems, hobbies, activities of interest, talents |
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Education 5 points
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No formal education Elementary school completed. Some high school-did not graduate. High school graduate College graduate |
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Employment: 5 points
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Unemployed Employed on Disability |
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Developmental 5 points
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History: Inquire about mother’s pregnancy and delivery, childhood with attainment of milestones, any learning disabilities or academic problems. |
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Psychiatric Review of Systems: 5 points
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Has patient ever experienced depression, anxiety, mania, ADHD, OCD, eating disorder, psychosis, trauma, personality disorder ? Medical Review of Systems: especially history of seizure or head trauma
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Objective |
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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 Formulation) Assets/strengths Liabilities Do full MMSE if memory concerns or over age 65 (score 1-30) |
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Assessment |
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Impression formulation 5 Points |
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 |
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Diagnosis 10 Points
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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) |
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Plan |
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Plan 10 Points |
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 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 |
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