Week 4 BM
4 months ago 10
HUInitialMHASOAPNoteTemplate11.docx
HUInitialMHASOAPNoteTemplate11.docx
Initial Psychiatric Interview/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.
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Criteria |
Clinical Notes |
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Informed Consent |
Before the psychiatric assessment and treatment commenced, informed consent was signed. The patient showed sufficient ability to know the risks, benefits and other options to care and accepted to be involved in medication management and psychotherapy.
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Subjective |
Patient Identification Name: N/A DOB: N/A
Demographics: African American female age 52. Gender: Female
Chief Complaint I am overloaded, never rested, and unable to stop worrying.
History of Present Illness (HPI) The patient is reporting to have the follow-up management of depression and anxiety. She complains of a 6-month history of chronic depressive symptoms such as depressed mood, sleepiness, poor concentration, and unwanted and uncontrolled worrying. These symptoms have become increasingly worse with the increased work stress and care giving roles. There is the interference of sleep with an average of four to five hours each night with frequent awakenings. She supports the idea of the appetite with recent weight gain. The patient rejects suicidal ideation, homicidal ideation, hallucinations and manic symptoms. Although she complains of an improvement in her symptoms partially with sertraline, she still reports having moderate functional impairment.
Past Psychiatric History Diagnosis of major depression disorder and generalized anxiety disorder. Denies previous psychiatric hospitalizations, suicide attempts.
Medical History Obesity; denies any cardiac, endocrine, or neurological history. Current Medications •Sertraline 100 mg orally in the morning. Hydroxyzine 25 mg orally two times daily as required in case of anxiety. •Vitamin D3 2,000 IU daily
Allergies No known drug allergies (NKDA)
Substance Use History Denies alcohol, tobacco, or illicit drugs.
Social History Working, and is a primary caregiver to a family member. Reports the presence of psychosocial stress.
Review of Systems (ROS) Positive insomnia, fatigue, hungry, and anxious. Any other system considered and is not contributory.
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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…” |
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Objective |
Stable; BMI elevated.
Mental Status Examination (MSE) The patient is alert and cooperative, is person, place, time, and situation oriented. She is well dressed and maintained. Mood is transpiring to be overwhelmed, and the anxious affect congruent. The speech rate and tone are normal. The thinking processes are rational and goal oriented. No delusions, hallucinations or disturbances in perceptions. She refutes suicidal or homicidal thoughts. Wisdom and wisdom are evaluated as just.
Laboratory Data Past laboratory findings were surveyed and in normal range.
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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. |
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Assessment |
DSM-5 Diagnoses
Major Depressive Disorder, recurrent, moderate (F33.1).
Generalized Anxiety Disorder (F41.1) Obesity, unspecified (E66.9)
The patient is still showing moderate symptoms with a partial response to SSRI therapy. At this point, no acute safety issues are detected.
Informed consent was given
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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.
Informed Consent Ability |
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Plan
(Note some items may only be applicable in the inpatient environment)
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Pharmacologic Interventions Maintain the sertraline of 100 mg orally daily; increase to 150 mg to the next visit in case symptoms are not sufficiently controlled. Hydroxyzine should be continued if there are acute symptoms of anxiety. Strengthen medication compliance and check side effects.
Non-Pharmacologic Interventions Referral to Cognitive Behavioral Therapy (CBT). Education on sleep hygiene, walking daily, breathing relaxation and journaling. Strategies of managing weight and improving nutrition discussed.
Safety Assessment The patient rejects suicidal/homicidal ideation and is rated to have a low acute risk.
Follow-Up Follow-up in four weeks to review medication or earlier in case of the aggravation of the symptoms.
Billing Codes 99214, 90833 Provider: __________ Date/Time: _______________
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HUInitialMHASOAPNoteTemplate11.docx
Initial Psychiatric Interview/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.
|
Criteria |
Clinical Notes |
|
|
|
|
Informed Consent |
Before the psychiatric assessment and treatment commenced, informed consent was signed. The patient showed sufficient ability to know the risks, benefits and other options to care and accepted to be involved in medication management and psychotherapy.
|
|
Subjective |
Patient Identification Name: N/A DOB: N/A
Demographics: African American female age 52. Gender: Female
Chief Complaint I am overloaded, never rested, and unable to stop worrying.
History of Present Illness (HPI) The patient is reporting to have the follow-up management of depression and anxiety. She complains of a 6-month history of chronic depressive symptoms such as depressed mood, sleepiness, poor concentration, and unwanted and uncontrolled worrying. These symptoms have become increasingly worse with the increased work stress and care giving roles. There is the interference of sleep with an average of four to five hours each night with frequent awakenings. She supports the idea of the appetite with recent weight gain. The patient rejects suicidal ideation, homicidal ideation, hallucinations and manic symptoms. Although she complains of an improvement in her symptoms partially with sertraline, she still reports having moderate functional impairment.
Past Psychiatric History Diagnosis of major depression disorder and generalized anxiety disorder. Denies previous psychiatric hospitalizations, suicide attempts.
Medical History Obesity; denies any cardiac, endocrine, or neurological history. Current Medications •Sertraline 100 mg orally in the morning. Hydroxyzine 25 mg orally two times daily as required in case of anxiety. •Vitamin D3 2,000 IU daily
Allergies No known drug allergies (NKDA)
Substance Use History Denies alcohol, tobacco, or illicit drugs.
Social History Working, and is a primary caregiver to a family member. Reports the presence of psychosocial stress.
Review of Systems (ROS) Positive insomnia, fatigue, hungry, and anxious. Any other system considered and is not contributory.
|
|
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 |
Stable; BMI elevated.
Mental Status Examination (MSE) The patient is alert and cooperative, is person, place, time, and situation oriented. She is well dressed and maintained. Mood is transpiring to be overwhelmed, and the anxious affect congruent. The speech rate and tone are normal. The thinking processes are rational and goal oriented. No delusions, hallucinations or disturbances in perceptions. She refutes suicidal or homicidal thoughts. Wisdom and wisdom are evaluated as just.
Laboratory Data Past laboratory findings were surveyed and in normal range.
|
|
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. |
|
|
Assessment |
DSM-5 Diagnoses
Major Depressive Disorder, recurrent, moderate (F33.1).
Generalized Anxiety Disorder (F41.1) Obesity, unspecified (E66.9)
The patient is still showing moderate symptoms with a partial response to SSRI therapy. At this point, no acute safety issues are detected.
Informed consent was given
|
|
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.
Informed Consent Ability |
|
|
Plan
(Note some items may only be applicable in the inpatient environment)
|
Pharmacologic Interventions Maintain the sertraline of 100 mg orally daily; increase to 150 mg to the next visit in case symptoms are not sufficiently controlled. Hydroxyzine should be continued if there are acute symptoms of anxiety. Strengthen medication compliance and check side effects.
Non-Pharmacologic Interventions Referral to Cognitive Behavioral Therapy (CBT). Education on sleep hygiene, walking daily, breathing relaxation and journaling. Strategies of managing weight and improving nutrition discussed.
Safety Assessment The patient rejects suicidal/homicidal ideation and is rated to have a low acute risk.
Follow-Up Follow-up in four weeks to review medication or earlier in case of the aggravation of the symptoms.
Billing Codes 99214, 90833 Provider: __________ Date/Time: _______________
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