Psychiatric SOAP notes

SOAP Note Components:

· Chief Complaint

· HPI

· Past Psychiatric History

. Age of manifestations of symptoms

. Previous Diagnoses and when they were diagnosed

. Psychotropic History

. All psychotropic medications

. Why stopped

. How long they were on

. Adherence

· Suicide Attempt/Homicidal Ideation History

· Legal History

· Trauma History

· Substance Use History

· Address

. Tobacco

. Alcohol

. Abuse of Prescription Drugs or Illicit Substances

· Length of time used substances

· Last Use

· Sobriety

· Detox/Rehab history

· Withdrawal Symptom History

· Social History

· Where born and raised

· Parental history

. Married or divorced during childhood

. Relationship with parents during childhood and now

· Siblings 

. How many and where they are in the order

· Any developmental issues

· Highest level of education

· Current employment status

. If on disability – list why they are on disability

· Relationship status 

. Married

. Divorced

. Single

. Widowed

· Children

. Number

. Ages

. Relationship 

· Living arrangements

. Who they live with

. Do they feel safe

· Past medical history/surgical history

· Family medical/psychiatric history

· Review of Systems/Physical Assessment

· Mental Status Exam

· Appearance

· Speech

· Mood

· Affect

· Thought Process

· Thought Content

· Cognition

· Insight

· Judgement

· Psychiatric Screening Tools if any are utilized during the appointment and their results (Example PHQ-9 is 21 and very difficult

· Diagnostic Tests Reviewed

· Make sure to include any pertinent results

. Laboratory results reviewed with patient, discussed abnormal Vitamin D level and treatment options

· If no issues with labs:

. Laboratory results reviewed with patient, no abnormal results noted

· Differential Diagnoses 

· With rationale

· 3 are required

· Must Include ICD codes

· Definitive Diagnoses 

· With rationale 

· Must Include ICD Codes

· It’s rare that patient’s only have 1 diagnosis

· The number of diagnoses can affect your reimbursement as a provider

· Treatment Plan/Plan of Care

. One of the most important parts of the note

. Include the following

. Medication management

. Medication, Dose, Route, Time

. State Reason for the Medication (I will mark down if this is not included in the plan)

. State reason for any changes 

. Discontinued Abilify related to side effects of weight gain

. Increase Lexapro to 10mg daily for depression and anxiety, if patient continues to have depressive symptoms may increase to 15mg at next appointment

. Decreased Seroquel to 100mg daily at bedtime for sleep as the patient c/o increased daytime fatigue

· Include a statement such as

. Risks, benefits and side effects were discussed in-depth with the patient.

. Patient’s medications were eprescribed and sent to the patient’s designated pharmacy

· Include any diagnostics that were ordered at this appointment

· Complementary and Alternative Approaches

· Include referral for therapy 

· Include type of therapy and why you are recommending

· Example

. Patient was referred for EMDR due to history of trauma

. Patient was referend for DBT due to history of borderline personality disorder

· Include any type of referrals for anyone else and why

· It is recommended that the patient follow-up with PCP for any medical issues.

· Will refer patient out for neuropsychological examination for cognitive decline

· Include Follow-Up appointment

· Include CPT Codes for visit

· Review billing guidelines for medical complexity and time

· If you are billing for time, make sure you include why it took that much time

· See Billing and Coding Presentation from APA about new billing and coding procedures for 2023.

· See presentation slides attachment for reference

Levels of Medical Decision Making

Levels of medical decision making will have four levels comprised of three elements: 

1. Number of Complexity of Problems Addressed

2. Amount and/or Complexity of Data to be Reviewed and Analyzed

3. Risk of Complications and/or Morbidity or Mortality of Patient Management. 

To qualify for a particular level of medical decision making and code at that level, a minimum of two of the three elements for that level of medical decision making must be met or exceeded. 

Time

Time reporting may be used for selecting the level of Evaluation and Management service  whether or not counseling or coordination of care dominates the service. Time is calculated as the total time spent personally by the provider on the date of the encounter, including both face-to-face and non-face-to-face time.

There are two built-in timers in Elation’s visit note that Provider level users can use to track their time on the day of an encounter. The timers are named  Time with patient and  Time documenting and are only visible to users who are logged in with provider-level accounts.