65Wk9P.JtT

Jane,

This is just a SOAP note for an adolescent patient. You can fill in any information that isn’t provided. You don’t have to add much if you don’t want because it is a young healthy kid. Do whatever you feel is best. Your judgement is always excellent. Thanks!

The Patient

Data:

Writer met with pt for 30-minute individual session. Pt is currently 16 years old, a sophomore in high school. Pt’s father accompanied him for the session. Pt reports feeling “numb the past 2 months”. Pt has always had many hobbies, including cars, hunting, fishing, and bike riding. Pt has lost interest in these activities. Pt reports sleeping til the afternoon on his days off from school. Pt does not report Anxiety, but rates his Depression 7/10. Writer discussed SSRI’s with the patient and his father. Writer ordered patient Zoloft 25mg daily.

Assessment:

Pt appears well-groomed with proper hygiene. Pt appears healthy. She is pleasant, calm, and cooperative. Speech is clear, with normal rate. She has a logical thought process. Pt denies suicidal ideation and homicidal ideation. Pt is not paranoid, denies hallucinations. Pt is alert and oriented to person, place, and time. Pt understands his need for professional help.

Plan:

Appointment in 4 weeks.