Unit 3 Clinical SOAP Note. 800w not anessay. Due late on 5-25-24

Psychiatric SOAP Note Template

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. Refer to the Psychiatric SOAP Note PowerPoint for further detail about each of these sections.

Criteria Clinical Notes Subjective Include chief complaint, subjective information from the patient, names and relations of others present in the interview, and basic demographic information of the patient. HPI, Past Medical and Psychiatric History, Social History. Objective This is where the “facts” are located. Include relevant labs, test results, vitals, and Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…” Include MSE, risk assessment here, and psychiatric screening measure results. Assessment Mini mental assessment goes here, normal for patient

ICD-10 code will be a 25 minute visit Diagnosis: ADHD Test performed is ADHD screening

Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes,

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treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment. Plan

-Start Adderall 5 mg PO daily, possible increase of dose to 10 mg depending on patient’s response to the treatment -EKG and basic labs, CBC, BMP to have a baseline level -Bring patient back in 2 weeks to follow up and see if treatment is effective. -Recommend relaxation techniques at night time and/or use Magnesium for anxious mood at night

Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy 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.

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Problem Focused SOAP NOTE-MDD

CC: “I was referred here by a behavioral health center where I voluntarily checked in for four days.”

Primary concerns for this visit

1. Establish care

2. Medication management

3. Counseling

Psychiatric Review of Systems

Depression: PHQ9 16/20 (6/10 pt rating)

Anxiety: 12/21 (7/10 pt rating)

Sleep: 8 hours/night- 10-11pm wakes up 7:45am to get to school by 8am

History of Trauma: Positive

Psychosis: denies

Mania: denies

Current Medications: Zoloft 25 MG PO daily for anxiety/depression; Vistaril 25 MG PO 1-2 tabs 6

times/daily prn anxiety

Side Effects: denies

Subjective: Patient is a 17-year-old male who presents to clinic today as a referral from inpatient

treatment where he voluntarily admitted himself on 3/21/23 for severe depression and anger. Patient

was discharged on 3/25/23. Patient states that while he was growing up his mother was addicted to

drugs. At age of 5 patient states he found his mother unconscious from drugs, which occurred many

times thereafter causing patient great fear and distress. Patient states his mother went to prison for

three years when he was in grade school. During that time his father abandoned the family, and he spent

those years with his grandmother who was a good caregiver but used a great deal of corporal

punishment. After his mother was released from prison client states she dated/lived with abusive drug

addicts who physically beat her regularly. Patient states this is why kids in his school continually make fun

of his mother because of the scars on her face and because of her weight. Patient describes always

having been depressed and afraid. Patient endorses serious anger issues. Patient states he gets teased at

school about his mother and this makes him angry, and patient states he subsequently becomes violent

and gets in many fights. Patient states he often is physically and emotionally abusive towards his younger

sister because she looks like his mother. Patient states he feels very bad about himself for treating her so

poorly but is unable to control his behavior. Patient states he is continually anxious and on edge most of

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the day. Patient states he tried to commit suicide by cutting himself on his abdomen in January of this

year. Patient never reported this to anyone until his recent admission to Peak View. Patient states he is

anxious about his grades because he states he wants to go to college on a scholarship to play sports.

However, patient states he has lost his motivation to get out of bed or even try doing good in school.

Patient states he is considered a loser and a stoner by his peers and states he decided to live up to

everyone's opinions of him. Patient states he actively goes out of his way to find the kids who tease him

so he can beat them up stating they usually cannot take even one of his punches. Patient states he has

many friends and enjoys a good social life with them. Patient also states he now has a good relationship

with his mother and considers himself "a mamma's boy," even though he endorses still being very angry

with her. Patient has little to no contact with his father and states he considers him "a piece of shit."

Patient denies current SI/HI. Patient denies delusions, hallucinations, and paranoia. Patient states he has

difficulty falling asleep but once asleep he sleeps throughout the night. Patient endorses frequent

nightmares and states he wakes up sweaty very frequently. Patient states his nightmares are comprised

of reliving "painful things I saw growing up." Patient states he is eating adequately but states he cannot

eat as much as he used to prior to starting his antidepressants. Patient also endorses difficulty focusing,

difficulty paying attention, being easily distracted, being hyperactive with great difficulty staying in his

seat in school. Patient states he sells marijuana and other drugs to afford food and clothing for himself

and his siblings.

Pt reports that sertraline is helping his depression, anxiety with no side effects. Pt reports that it is hard

to focus in school, and that he is failing art, math and science. Pt reports he will not get held back if

parents don't want him to. Pt reports getting into fights after school so not in danger of getting

suspended or expelled. Pt has IEP contract so that he can go and talk to a teacher or school counselor, pt

reports uses this privilege often. Pt reports sometimes feels like his vision goes black when he's angry.

Patient has a 17-year-old brother who knows how to make him angry, and they got into brawls regularly.

Objective-Patient’s thoughts are logical, concrete, and lucid. Affect is flat and mood is sad/depressed.

Speech is clear, non-hurried and organized. Patient’s dress is clean and appropriate. Attitude is

cooperative and pleasant. Psychomotor activity is normal except for a jittery right leg which patient

attributes to nervousness. Memory, judgement, and insight are all intact.

Assessment-Client meets DSM-V criteria for MDD. Also, patient does present with numerous symptoms

of PTSD and ADHD. The working diagnosis for now will be MDD.

Plan-Patient will take an on-line cognitive evaluation to rule in/out ADHD. Patient will be starting

counseling with one of our staff counselors for added insight into patient’s possible other diagnoses. For

now, patient will remain on present medication regimen as he’s only been on these medications for a

little over one week. Will monitor and evaluate patient’s response and consider dosage

changes/increases at subsequent visits. Once cognitive evaluation is resulted, if positive for ADHD will

consider adding Strattera or Guanfacine to medication regiment. Patient should benefit greatly from

weekly counseling.

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Psychiatric SOAP Note Template

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. Refer to the Psychiatric SOAP Note PowerPoint for further detail about each of these sections.

Criteria Clinical Notes Subjective Patient Information: EH, 15-year-old, Caucasian female

CC: “I am concerned about my daughter’s weight loss and excessive

exercising.”

HPI: EH presents with her mother for evaluation related to concerns

pertaining to intentional weight loss that began a year ago, which she

now deems has become concerning. Mom reports EH has lost 30

pounds over the past 12 months, 20 pounds of which she has lost

during the last six months. EH admits to restricting her

caloric/carbohydrate intake, binging and purging, abusing laxatives,

and exercising three to four hours a day. Moreover, EH reports

anxiety related to her “supposed” weight issue and a desire to lose

five more pounds.

Current Medications: None at present time

Allergies: NKDA

Past Medical History

Metatarsal stress fracture (March 2019)

Childhood obesity

No hospitalizations

Surgical History: Unremarkable

Include chief complaint, subjective information from the patient, names and relations of others present in the interview, and basic demographic information of the patient. HPI, Past Medical and Psychiatric History, Social History.

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Social History

Full-time high school student (straight A student)

Lives with mother

Denies alcohol and recreational drug use

Heterosexual, not sexually active at present time, not involved in a

relationship

Family History

Unremarkable psychiatric history other than cousin with eating

disorder Objective

ROS

ROS negative with the exception of:

Constitutional: 30-pound intentional weight loss/12 months, (+)

fatigue

Gastrointestinal: Denies abdominal pain, blood, or coffee ground

emesis (+) constipation

Genitourinary: Denies dysuria, frequency, or hematuria. LMP:

“maybe three months ago,” irregular menses, denies pregnancy, not

sexually active

Neurological: Fainted once during volleyball game, attributes to

heat. Denies headache, dizziness, ataxia, numbness or tingling in the

extremities

Psychiatric: Denies history of depression, anxiety, or eating disorder

EXAM

This is where the “facts” are located. Include relevant labs, test results, vitals, and Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…” Include MSE, risk assessment here, and psychiatric screening measure results.

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VS: weight 100 pounds, 5’ 7” BMI 15.7 temp, 95.9, pulse oximetry

99% (unable to figure out how to obtain remainder of VS)

Mouth: Cracked lips, mild angular stomatitis

Skin, hair, nails: Lanugo, dry, rough skin, abrasions and calluses on

dorsa of right hand

Cardiac: Orthostatic hypotension (I was not able to take vitals but

noted this finding in case study)

Gastrointestinal: Abd lean, non-distended, (+) BS x 4, non-tender, no

organomegaly

OBJECTIVE

VS: weight 100 pounds, 5’ 7” BMI 15.7 temp, 95.9, pulse oximetry

99% (unable to figure out how to obtain remainder of VS)

Mouth: Cracked lips, mild angular stomatitis

Skin, hair, nails: Lanugo, dry, rough skin, abrasions and calluses on

dorsa of right hand

Cardiac: Orthostatic hypotension (I was not able to take vitals but

noted this finding in case study)

Gastrointestinal: Abd lean, non-distended, (+) BS x 4, non-tender, no

organomegaly

MSE

Appearance: Thin, emaciated, young lady, dressed in loose attire.

Rough skin and thin hair. Abrasions and calluses are noted on the

dorsa of her right hand. Initially reserved but able to establish good

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rapport towards the end of examination.

Behavior/Activity: Fidgety throughout the consultation

Speech: Spontaneous, normal rate, tone, and flow

Thought form: Logical and goal directed

Thought content: Glorified ideas on her weight. Although she is

preoccupied with the fear of being overweight, she does not exhibit

an obsession. No hallucinations or delusions are noted.

Mood: Mild dysphonia

Affect: Reactive

Suicidal Ideation: None

Homicidal Ideation: None

Orientation: A/O x 3

Memory: Immediate, recent, and remote memory intact

Judgment/Insight: Poor, does not recognize weight loss to be a

problem but nonetheless she is willing to participate in treatment

Attention/Concentration: Intact

SCREEINGS

EAT-26 > 20 (positive for eating disorder evaluation)

HAM-D: Not resulted

DIAGNOSTICS

12 lead EKG: Borderline sinus bradycardia: Rate 60

T-wave flattening, ST depression, and QT prolongation

CMP: hypokalemia 3.2

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Phosphorus, magnesium, HCG, TSH, TFT: WNL

Assessment DIAGNOSIS

Anorexia nervosa, binge eating/purging type, F50.02

DSM-5 criteria for anorexia nervosa, binge eating/purging type

includes the following:

 restriction of energy intake relative to physiologic

requirements

 overwhelming fear of putting on weight or becoming

overweight, or persistent behavior that impedes weight gain,

although already at a significantly low weight

 body image perception disturbance or persistent lack of

awareness of the gravity of

actual low BMI

engagement in self-induced vomiting or laxative misuse over

previous three months (American Psychiatric Association,

2013).

Moreover, EH presented with the following clinical signs, which are

common to individuals suffering from anorexia nervosa:

 amenorrhea

 bradycardia (borderline)

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.

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 brittle nails and fine hair

 hypokalemia

 lanugo

significant weight loss (Harrington, Jimerson, Haxton, &

Jimerson, 2015).

OBSTACLE(S) TO TREATMENT

 Poor self-esteem

 Limited peer support system

 Poor judgment/insight, does not grasp gravity of current

situation as she continues to insist on losing five more

pounds.

Plan PLAN

APA criteria for inpatient admission for anorexia nervosa includes the

following:

 heart rate less than 50 beast/minute during the day and 45

beats/minute during the night

 systolic blood pressure less than 90

 orthostatic changes in pulse or blood pressure

 arrhythmia

 temperature less than 96 °F

 less than 75% ideal body weight or continued weight loss

Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options and complimentary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive

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plan should relate directly to your Assessment.

regardless of intensive therapy

 refusal to eat

 outpatient treatment failure (Campbell & Peebles, 2014).

Although I was not able to fully calculate EH’s vital signs due to my

inexperience with the iHuman program, I feel that she eseentially

meets criteria to be admitted to the hospital based on her clinical

presentation and poor insight and judgement.

References

American Psychiatric Association. (2013). Diagnostic and statistical

manual of mental disorders (5th ed.). Washington, DC:

American Psychiatric Publishing.

Campbell, K., & Peebles, R. (2014, September). Eating disorders in

children and adolescents: States of the art review. Pediatrics,

134(3). Retrieved from

https://pediatrics.aappublications.org/content/134/3/582

Harrington, B. C., Jimerson, M., Haxton, C., & Jimerson, D. C.

(2015, January). Initial evaluation, diagnosis, and treatment of

anorexia nervosa and bulimia nervosa. American Family

Physician, 1(91), 46-52. Retrieved from

https://www.aafp.org/afp/2015/0101/p46.html

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