Bb 7 soap note

SOAP Note (Psychiatric Follow-up Template)

S-Subjective:

Client identifying information: Patient’s Initial, DOB, other identifying information

Chief Compliant: “Stated in the patient’s own words”

History of Present Illness: Timing of symptoms (when did symptoms begin), quality, severity, setting, aggravating factors, associated symptoms? What has been helpful in alleviating symptoms?

The OLD CARTS mnemonic is a structured clinical tool used to guide the History of Present Illness by systematically capturing key dimensions: Onset (when the symptom began), Location (where it’s felt), Duration (how long or often it occurs), Character (what it feels like), Aggravating/Alleviating factors (what makes it worse or better), Radiation/Relief (whether it spreads or what relieves it), Timing (patterns or frequency), and Severity (how intense and how it affects daily life).

Sleep: quality, amount

Appetite and weight: Increased/decreased, gain/loss

Psychomotor agitation/retardation: agitated, feel sluggish

Anhedonia: unable to master interest as before

Concentration: unable to concentrate/think clearly about things

Guilt/Worthlessness: sense of guilt or worthlessness

Medication Side effects: What are the side effects

Note this should be written in a paragraph. PAST MEDICAL, FAMILY, AND SOCIAL HISTORY UPDATE (including substance use): State the patient’s current employment status, substance use (current/history), overall health condition, and present living situation.”

Prior substance abuse treatment programs (detox, rehab, IOP): Denied Alcohol (blackouts, tremors, seizures): Denied Sedatives or sleeping pills (benzos, Ambien): Denied Opioids (pills, heroin, kratom, overdoses, IV drug use, MAT): Denied Cannabis: Medical uses Nicotine: Denied Cocaine: Denied Methamphetamine: Denied Stimulant medications: Denied Hallucinogens (LSD, mushrooms, salvia): Denied Club drugs (ecstasy, ketamine, PCP, GHB): Denied Other (steroids, bath salts, Spice/K2): Denied Longest time sober (without any substance use other than nicotine): N/A Payment history (work, drug dealing, stealing, trading sex): Denied

O-Objective:

MENTAL STATUS EXAM:

Appearance: Well-groomed, disheveled, older than stated age, malodorous, appropriately dressed

Behavior: Calm, cooperative, guarded, agitated, withdrawn, restless, distracted

Speech: Normal rate/rhythm, pressured, slow, monotone, loud, soft, slurred, articulate

Mood (subjective) “Depressed,” “anxious,” “angry,” “okay,” “hopeless,” “irritable,” “numb”

Affect: (objective) Congruent/incongruent with mood, flat, blunted, labile, restricted, full range

Thought Process: Logical, linear, goal-directed, tangential, circumstantial, disorganized, flight of ideas

Thought Content: Normal, suicidal ideation, homicidal ideation, obsessive thoughts, paranoid, delusional

Perception: No hallucinations, auditory hallucinations, visual hallucinations, illusions

Cognition: Alert, oriented ×3 (person/place/time), oriented ×4 (+situation), disoriented

Attention/Concentration: Intact, easily distracted, impaired, unable to spell “world” backwards

Memory: Intact, short-term impaired, recent impaired, remote memory intact

Insight: Good, fair, poor, lacks awareness of illness

Judgment: Intact, impaired, poor, limited, impulsive

Reliability: Reliable historian, questionable reliability, vague or evasive responses

Other Objective Information:

Vital Signs, Height, Weight, BMI, EKG, (any psychological testing if available).

Screening Tools: PHQ9, GAD7, Beck Depression Inventory etc.

LABS/Pregnancy Test/Toxicology:

CURRENT MEDICATIONS:

Psychotropic:

Non-psychiatric:

Vitamins and supplements:

A-ASSESSMENT:

Restate symptoms reported in HPI in a short paragraph.

Primary Psychiatric Diagnosis with specifier (if known), severity, when applicable, ICD-10. (List Criteria as stated in the DSM V-TR, identify which are MET and or NOT MET and provide 1-2 sentences to provide explanation/rationale.

Medical diagnoses if known:

Contextual Factors (Z codes): External influences that impact a patient’s mental health but are not mental disorders; they provide psychosocial, environmental, and situational stressors (e.g. homelessness, problems in relationship with a spouse or partner).

List one differential diagnosis, other disorders that are similar in nature such as criteria, so should be considered in the case. Provide a brief explanation of the rationale.

Visit code:

Time Spent with patient:

Type of visit: Face to Face in office visit/Telehealth-virtual visit/etc.