SOAP NOTES

SOAP Notes

· Students will be required to complete one SOAP (psych) note on a patient seen in the practicum setting each week.

· These need to follow the guidelines for writing SOAP notes (S = Subjective, O = Objective, A = Assessment, P = Plan) and include relevant history, physical findings, assessment, and interventions.

· Student is required to submit one SOAP NOTE on the assigned patients in order to receive grade.

· Find Template for SOAP Note in the syllabus OR under TEMPLATES on the left hand navigator of blackboard.

PLEASE USE BELOW

Sample template DO YOUR PSYCH SOAP NOTES

· Student Name: _____________________________________________

· SOAP Note #___________Source of Information:

· Patient Information

· 􀁸 Gender

· 􀁸 Height and Weight

· 􀁸 Marital status

· 􀁸 Occupation

· 􀁸 Current medication

· 􀁸 Past Psychiatric medication

· 􀁸 Allergies

· 􀁸 Chief complaint: describe the reason for the visit and chief complaint

· 􀁸 Describe history of present illness, including analysis of symptoms

· 􀁸 Medical history

· 􀁸 Psychiatric history (age of onset, diagnosis, previous treatments, hospitalization)

· 􀁸 Family history

· 􀁸 Psychosocial/Developmental History

· 􀁸 Substance Use History

· 􀁸 Current or Past Legal History

· 􀁸 Current or Past Truma

· 􀁸 Current or Past Abuse

· 􀁸 Review of Systems (no significant issues revealed, CV, Renal, GI, Hepatic, CNS, GU, CA, Metabolic, Pulm, GYN, HIV)

· 􀁸 Mental Staus exam

· 􀁸 Screening tests/symptom scales Performed

· 􀁸 Strengths/Limitations

· 􀁸 Include any objective data you have now, including labs

· Assessment:

· 􀁸 Identify diagnosis, including differential diagnosis and rationale

· 􀁸 Case Formulation

· Plan:

· 􀁸 List plan of care, including medication (Evidence Based Practice) and rationale

· 􀁸 Describe any needed lab work with rationale

· 􀁸 Identify alternatives to this plan

· 􀁸 Referrals

· 􀁸 How soon should the patient return for follow-up and why?

· 􀁸 Was this patient an appropriate patient for a nurse practitioner? Is a nurse practitioner the

· appropriate provider of follow-up care for this patient?

· 􀁸 Was this a health care encounter that required consultation or collaboration with another

· health care provider?

· 􀁸 If yes, to whom should the patient be referred? Is this type of provider available in the

· community?

· Education:

· 􀁸 What education does this patient/family need?

· 􀁸 What community resources are available in the provision of care for this client?

· References:

· 􀁸 List references in APA style (more than 2 is required; one reference must be a journal

· using evidence-based practice, no more than 1 website reference, references should be no

· more than 5 years old)

·