Psychopharma (SOAP NOTE)
MR25
PHMNP_SOAP_Note_PPT_SP120.ppsxPsychiatric SOAP Note Presentation
Regis College
PMHNP Program
Edited 10-14-18, AM, CG & BF
Outline
What is Psychiatric SOAP Note?
What does it look like?
What does it include?
Breakdown of S, O, A, P
What is a Psychiatric SOAP Note?
SOAP
Subjective
Objective
Assessment
Plan
SOAP is a way to help track progress of patients
Helps with documentation, organization
Done at each visit
Mix of bullet points, narrative
Different from medical SOAP note
Less focus on medical testing, review of systems
What does SOAP look like?
Dependent on the organization you work for
Electronic health record (EHR), paper forms
Length varies on case
Purposes in PMHNP Program
Need to show application of materials to patient cases
Understand resources available as students and future clinicians
Simplifies and promotes organization of information to facilitate diagnosis and treatment planning
What does SOAP include?
4 Components
Subjective
Objective
Assessment
Plan
“S” Subjective from PMHNP SOAP Template
| 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. |
Aspects of “S”
Chief Complaint, description
Subjective Information: name, date of birth, sex, identifying data, preference for name/pronouns
Location of Interview
People Present for Interview
History of the Present Illness (HPI) which documents the patient’s current condition
Medical History: diagnoses, medical hospitalizations, medical and surgical procedures, head and body trauma (loss of consciousness, concussions)
Psychiatric History: psychiatric hospitalizations, partial hospitalizations, intensive outpatient programs, residential program treatment, individual and groups therapies, ECT/TMS/Ketamine Treatments, past suicide/homicide attempts, self-injurious behaviors
Family Psychiatric History: suicides, homicides, attempts, long-term institutional treatment of family
Medication History: vitamins, psychotropic and other medications, birth control, relevant blood work and tests
Social History: school completion, work history, legal history, living situation
Substance Use: Alcohol, Drugs (oral and injectable and inhalation routes considered), Smoking Status – current and past
“O” Objective from PMHNP SOAP Template
| Criteria | Clinical Notes |
| 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. |
Aspects of “O”
Patient’s physical appearance with descriptive words
Review of Systems (ROS): not as extensive as medical ROS, “ROS noncontributory” or “ROS negative except for …” Document abnormal findings like “shuffling, tremors,” etc.
Vital signs, if available
Lab results, if available
Complete Mental Status Exam (MSE)
Risk Assessment
Screening Results – Measures like the CAGE, AUDIT, etc.
“A” Assessment from PMHNP SOAP Template
| Criteria | Clinical Notes |
| Assessment | |
| 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. |
Aspects of “A”
Working primary diagnoses
Current differential diagnoses
Concurrent diagnoses including Medical Diagnoses
DSM-V diagnoses, ICD-10 codes
“P” Plan from PMHNP SOAP Template
| Criteria | Clinical Notes |
| Plan | |
| 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. |
Aspects of “P”
Diagnostic: collateral information, releases obtained, safety planning, testing plans
Specific Treatment: medications (dose, route, titration plan), psychotherapy plans, education, non-pharmacologic interventions: nutrition, exercise
Disposition: next steps, follow-up plan, potential future treatment steps
