SOAP 3

1. SOAP Notes

IMPORTANT:

Notes are to represent real clients seen by you in clinic and information must also be reflected in your InPlace or Typhon folder of clinical patients. Information leading to discovery of a “made up” note will be cause for course failure.

Each student will complete three (3) SOAP notes. SOAP Notes are to be posted to the DB in a copy & paste fashion for ease of reading and reference. Please do not attach a link to the document These Soap Notes will stimulate discussion, questions, and critique by peers and instructors. Soap Notes are to be posted in weeks 1, 5, and 9 by Saturday at 11:59. Discussion including at least one meaningful response to at least one of your peers’ Soap Notes should occur by Thursday at 11:59pm EST in weeks 2, 6, and 10. A meaningful response is one that demonstrates critical thought. Refer to the Carlat, Zuckerman, and Kaplan & Sadock texts for assistance. Posts that are perfunctory or only minimally meeting all grading criteria do not necessarily qualify as “excellent” which would yield full points (100). This is true for both the initial post and the response post. One response post is considered to minimally meet criteria.

Purpose: To record information from the patient, family members, friends, other data bases, other professionals (nurses, physicians, labs, X-ray, Etc), in order to accurately ascertain the information which you need to know about the patient and their disease process(es), so that you can make an accurate diagnosis and provide advice on the most appropriate treatment. The written record also provides a means of communication between you and your professional colleagues. It should be written in a manner which allows the reader to “see” what you observed, performed, discussed and plan to do for and with the patient. SOAP notes are generally done as a follow up after an initial H & P (Psychiatric evaluation) has been done.

Name of Patient:

Date of Service:

S: Subjective information of interest from patient

O: Objective clinical information of interest you observe and hear; Mental Status Exam (MSE)

A: DSM-5 diagnosis(es) and specifiers supported by clinical/historical information with ICD-code(s)

P: Plan of care including medications (trade/generic name, delivery type, dose, route, timing, length of prescription, # of refills), psychotherapy, medication education, crisis planning, and recommendations for next scheduled appointment.

Signature/credentials

*Each SOAP Note submitted after the due date will be penalized five (5) points per day, including weekends.

Syllabus 2016-2017

SOAP NOTE FORMAT/EXAMPLE: (Note: This example is not exhaustive and yours must include additional data such as elaboration of rationale, neurobiology, or other information important for an academic exercise but not necessarily appropriate for a clinical document in practice)

PSYCHIATRIC PROGRESS NOTE (SOAP)

NAME: Doe, John DATE: 05/1/2014

Subjective: CC: “I was in the hospital”. John is seen today as a status post hospitalization visit. He was hospitalized at from 04/26/14 to 04/30/14. He was apparently admitted for increased agitation and aggression, making threats toward his mother and his niece, with whom he had been living. John states that he does not believe he had been taking his medications correctly, but he also acknowledges that there was increased stressors at the time of hospitalization with his mother and his niece. It is not clear how long John had been living with his mother and niece. The last time he was seen at this clinic was in March of 2010 and he was a resident of Bellvue Personal Care Home. He now resides back at Bellvue Personal Care Home after discharge. John was stabilized and then discharged on his previous medication regimen. He was given a diagnosis of Chronic Paranoid Schizophrenia. However, John appears to have a significant mood component and has been diagnosed with Schizoaffective Disorder, which will continue to be his working diagnosis. John also states that he has quit smoking. He has not smoked in six days and plans to continue abstinence. His sleep, appetite, and weight remain stable.

Objective MSE: The patient is casually dressed and groomed. He looks very good today. He has good skin color. He is alert. He appears to be in good spirits. He makes good eye contact. He is calm and cooperative. Speech is regular in rate and tone, relevant, with some latency of response. Thoughts appear to be goal directed. He relates his mood as “good”. Affect is restricted. He denies any mood lability or instability, nor is there any noted. There is no evidence of any delusional thinking. There is no evidence of any perceptual disturbances. There is no evidence any suicidal or homicidal ideation and he denies same. He is alert and oriented X three.

Assessment:

Schizoaffective Disorder, Nicotine Use Disorder, Panic Disorder with Agoraphobia, Mild Intellectual Disability,Peptic Ulcer Disease; Gastritis; Hyperlipidemia;Obesity; Type II Diabetes; Early Diabetic Retinopathy;Disc Disease; Abnormal Tongue Movements; History of Thyroid Disease;Recent hospitalization and Housing issues

Current Medications:

a. Geodon 80 mg, po bid

b. Clonazepam 1 mg po qid

c. Fluoxetine 40 mg one po q day

d. Lithium Carbonate 300 mg, three tablets po q h.s.

Plan:

Continue with John’s current medication regimen. He has been doing well since discharge. He relates that he has been getting along with everyone at Bellevue. He has not had any further problems with anger, aggression, or agitation. During his previous residence at Bellevue, he was somewhat disgruntled and was seeking different housing; however, it appears that once than happened and he moved in with his mother his stressors increased and he destabilized. He is working with his caseworker to find alternative housing that would be appropriate. He will also continue in outpatient therapy with. John verbalizes understanding of, and is in agreement with, this treatment plan. He is encouraged to contact this office with further questions or concerns. He will be return to the office in four weeks for reevaluation, or sooner, as needed.

SOAP Grading sheet

Points
20 points 20 points 15 points 20 points 10 points 15 points	A. S Subjective data appropriately documented. Chief complaint, interval history and review of symptoms B. O Objective data appropriately documented. Vitals, review of testing and lab work, MSE C. A Assessment appropriately documented. Review diagnoses and current treatment plan for accuracy and relevance. D. P Plan to include cost-effective and evidence based treatment. Include labs to order, meds and dosage, counseling and referrals, teaching plan, follow up (add to what was actually done if you would do something other than your preceptor- in italics); E. Include neurobiology of disorder(s). (Include genetics, neurotransmitters, neuroanatomical changes, current theories of causation, cultural factors); F. Rationale for each part of management plan (labs; meds: why this med, what is neurochemistry action of med, side effects to monitor, expected benefits, contraindications; counseling-goals, rationale for this type of therapy, expected benefits, teaching, referrals, follow-up). Include references from at least 3 sources including one article from refereed journal.
Grade

Demographics: 57-year-old male, married, retired U.S. Army veteran.

Visit Type: Initial comprehensive psychiatric evaluation via telemedicine.

Reason for Visit: Evaluation of worsening trauma symptoms, depression, irritability, sleep disturbance, and increased alcohol use.

Chief Complaint: “I’m always on guard. I don’t sleep well, and my family says I’ve become angry and distant.”

Psychiatric Diagnoses:

· Post-traumatic stress disorder (F43.10)

· Major depressive disorder, recurrent, moderate (F33.1)

· Alcohol use disorder, moderate (F10.20)

Medical Comorbidities: Hypertension and chronic back pain.

Current Medications:

· Losartan 50 mg PO daily

· Acetaminophen PRN pain

· No current psychiatric medications

Social Problems Addressed: Adjustment to civilian life, marital conflict, social isolation, chronic pain, loss of military structure, and increased alcohol use.

Trauma/Substance History: Reports combat exposure during Army deployments, including witnessing deaths and serious injuries. Reports intrusive memories, nightmares, avoidance, hypervigilance, and exaggerated startle response. Drinks approximately 3–4 alcoholic beverages most evenings to relax and sleep.

Procedures: Comprehensive psychiatric evaluation, MSE, PTSD/depression assessment, military trauma assessment, alcohol-use/withdrawal-risk screening, medication reconciliation, sleep and functional assessment, and suicide risk assessment.

Clinical Note: Patient reports worsening combat-related nightmares, intrusive memories, hypervigilance, irritability, depressed mood, poor sleep, and increasing social withdrawal. He reports drinking most evenings to manage anxiety and sleep and acknowledges that alcohol has contributed to conflict with his wife. Denies mania, psychosis, SI, or HI.

SOAP Note

S: Reports nightmares, intrusive memories, hypervigilance, irritability, depression, insomnia, isolation, and increased alcohol use. Symptoms are affecting his marriage and daily functioning. Denies SI/HI.

O: A&O ×4, appropriately groomed and cooperative. Mood depressed/irritable; affect constricted. Speech normal. Thought process linear and goal directed. No overt psychosis. Insight and judgment fair.

A: PTSD related to military combat exposure with recurrent MDD and moderate alcohol use disorder.

P: Start sertraline 25 mg PO daily, increasing to 50 mg daily as tolerated. Recommend trauma-focused psychotherapy and substance-use treatment. Assess withdrawal risk before significant alcohol reduction and avoid abrupt unsupervised cessation if physiologic dependence is present. Encourage structured daily activities and veteran support resources. Monitor PTSD symptoms, mood, alcohol use, sleep, and medication tolerability. Safety reviewed. Follow up in 1–2 weeks.

New Medication: Sertraline 25 mg PO daily → 50 mg PO daily as tolerated

Psychotherapy: No Telemedicine: Yes Activity Time: 60 minutes Complexity: High CPT: 90792 ICD-10-CM: F43.10, F33.1, F10.20

SOAP 2

Demographics: 68-year-old male, married, retired U.S. military veteran, lives with his wife.

Visit Type: Initial comprehensive psychiatric evaluation via secure audio/video telemedicine.

Reason for Visit: Evaluation of worsening trauma symptoms, depression, irritability, poor sleep, and increasing withdrawal since retirement.

Chief Complaint: “Since I retired, I have too much time to think. The memories are coming back and I’m getting more irritable.”

Psychiatric Diagnoses:

· Post-traumatic stress disorder (F43.10)

· Major depressive disorder, recurrent, moderate (F33.1)

· Insomnia disorder (F51.04)

Medical Comorbidities:

· Hypertension

· Coronary artery disease

· Chronic knee osteoarthritis

Social Problems Addressed: Adjustment to retirement, loss of daily structure and purpose, marital tension, reduced social engagement, chronic pain, and avoidance of discussing military experiences.

Current Medications:

· Losartan 50 mg PO daily

· Aspirin 81 mg PO daily

· Atorvastatin 40 mg PO daily

· No current psychiatric medications

Trauma History: Reports combat exposure during military service, including witnessing deaths and serious injuries. He has historically avoided discussing these events but reports increasing intrusive memories, nightmares, hypervigilance, and exaggerated startle response since retirement.

Procedures: Comprehensive psychiatric evaluation, MSE, PTSD/depression assessment, military trauma history, sleep assessment, medication reconciliation, substance-use screening, functional assessment, cognitive screening, and suicide risk assessment.

Clinical Note: Patient reports increasing intrusive memories, nightmares, hypervigilance, irritability, depressed mood, poor sleep, and social withdrawal since retiring. He reports feeling that he has lost his sense of purpose and spends much of his day at home, which has contributed to increased recollection of combat experiences. His wife has expressed concern about his irritability and emotional withdrawal. Denies current mania, psychosis, substance misuse, SI, or HI.

SOAP Note

S: Reports recurrent combat-related nightmares, intrusive memories, hypervigilance, irritability, depressed mood, decreased interest in activities, poor sleep, and increasing social isolation. He reports difficulty adjusting to retirement and loss of his previous routine. Denies SI/HI.

O: Telemedicine MSE: A&O ×4, appropriately groomed and cooperative. Mood depressed and mildly irritable; affect constricted and congruent. Speech clear and normal in rate. Thought process linear and goal directed. No overt psychosis. Attention and memory grossly intact. Insight and judgment fair.

A: PTSD related to military combat exposure with concurrent MDD and insomnia. Retirement, decreased structure, chronic pain, and social withdrawal are contributing to current symptom burden.

P: Start sertraline 25 mg PO daily for 1 week, then increase to 50 mg PO daily as tolerated. Recommend trauma-focused psychotherapy through veteran or community mental-health services and encourage gradual re-engagement in structured and meaningful activities. Address insomnia with sleep-hygiene interventions initially and reassess need for additional treatment after mood/PTSD symptoms are addressed. Monitor mood, sleep, blood pressure, medication tolerability, and safety. Follow up in 2–4 weeks.

New Medication: Sertraline 25 mg PO daily → 50 mg PO daily as tolerated

Psychotherapy during visit: No Telemedicine: Yes – secure audio/video Activity Time: 60 minutes Complexity: High CPT: 90792 ICD-10-CM: F43.10, F33.1, F51.04

SOAP 3

Demographics: 74-year-old male, U.S. military veteran, married, retired, lives with his wife.

Visit Type: Initial comprehensive psychiatric evaluation via secure audio/video telemedicine.

Reason for Visit: Evaluation of worsening trauma-related symptoms, depression, sleep disturbance, and increasing social withdrawal.

Chief Complaint: “The memories are coming back more lately. I’m not sleeping well, and I’ve been keeping to myself.”

Psychiatric Diagnoses:

· Post-traumatic stress disorder (F43.10)

· Major depressive disorder, recurrent, moderate (F33.1)

Medical Comorbidities:

· Hypertension

· Type 2 diabetes mellitus

· Osteoarthritis

· Chronic back pain

Social Problems Addressed: Social isolation, retirement adjustment, chronic pain, decreased mobility, difficulty discussing military experiences, and reduced participation in social activities.

Current Medications:

· Losartan 50 mg PO daily

· Metformin 500 mg PO BID

· Acetaminophen PRN pain

· No current psychiatric medications

Trauma History: Reports exposure to combat and witnessing deaths and serious injuries during military service. He describes longstanding avoidance of discussing these experiences, with recent increases in intrusive memories and nightmares.

Procedures: Comprehensive psychiatric evaluation, MSE, PTSD/depression assessment, military trauma history, cognitive and functional assessment, medication reconciliation, sleep assessment, substance-use screening, fall-risk assessment, and suicide risk assessment.

Clinical Note: Patient reports increasing intrusive memories, nightmares, hypervigilance, poor sleep, depressed mood, decreased motivation, and social withdrawal related to past combat experiences. He reports that retirement, chronic pain, and spending more time at home have contributed to increased recollection of military trauma. His wife has noticed that he has become more withdrawn and irritable and rarely participates in activities he previously enjoyed. Denies mania, psychosis, substance misuse, SI, or HI.

SOAP Note

S: Patient reports recurrent combat-related nightmares and intrusive memories, hypervigilance, irritability, depressed mood, anhedonia, fatigue, and increasing isolation. Sleep is frequently interrupted by nightmares. Denies SI/HI.

O: Telemedicine MSE: A&O ×4, appropriately groomed and cooperative. Mood depressed; affect constricted and mildly anxious. Speech clear and normal in rate. Thought process linear and goal directed. No overt psychosis. Attention and memory grossly intact during interview. Insight and judgment fair.

A: PTSD related to military combat exposure with concurrent MDD, recurrent, moderate. Chronic pain, reduced mobility, retirement, and social isolation appear to contribute to current functional impairment.

P: Start sertraline 25 mg PO daily with cautious titration based on response and tolerability. Recommend trauma-focused psychotherapy through an appropriate veteran/community mental-health program and encourage gradual re-engagement in meaningful social activities. Monitor mood, PTSD symptoms, sodium as clinically indicated, fall risk, and medication adverse effects. Consider targeted treatment for persistent trauma-related nightmares after reviewing response to initial treatment and blood pressure/orthostatic risk. Safety plan reviewed. Follow up in 2–4 weeks.

New Medication: Sertraline 25 mg PO daily

Psychotherapy during visit: No Telemedicine: Yes – secure audio/video Activity Time: 60 minutes Complexity: High CPT: 90792 ICD-10-CM: F43.10, F33.1