Bm 7 soap notes
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files (2)SOAPPsychiatricFollow-up28129.pdf
7_Additional_Mental_Health_Charts.docx
SOAPPsychiatricFollow-up28129.pdf
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Behavior: Calm, cooperative, guarded, agitated, withdrawn, restless, distracted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.
7_Additional_Mental_Health_Charts.docx
Additional Mental Health Patient Charts
Chart 8
Age: 27
Race: Black/African American
Gender: Male
Chief Complaint: I feel overwhelmed and stressed.
HPI: Patient reports excessive stress related to work demands, irritability, fatigue, and poor sleep for 2 months. Denies SI/HI/AH/VH.
CPT 9: 90834
CPT 10: 99213
ICD-9: 309.24
Medication: Buspirone 5 mg PO BID
Education: Discussed stress management, healthy coping mechanisms, sleep hygiene, relaxation exercises, and medication adherence.
Chart 9
Age: 58
Race: Hispanic
Gender: Female
Chief Complaint: I keep reliving my trauma.
HPI: Patient reports nightmares, flashbacks, hypervigilance, and avoidance behaviors following a motor vehicle accident 1 year ago. Denies SI/HI.
CPT 9: 90837
CPT 10: 99214
ICD-9: 309.81
Medication: Prazosin 1 mg PO at bedtime
Education: Reviewed PTSD symptoms, grounding techniques, trauma-focused therapy options, medication side effects, and safety planning.
Chart 10
Age: 19
Race: White
Gender: Female
Chief Complaint: I panic in social situations.
HPI: Patient reports intense fear during social interactions, avoidance of public speaking, sweating, trembling, and nausea when around groups. Symptoms ongoing for several years.
CPT 9: 90832
CPT 10: 99213
ICD-9: 300.23
Medication: Fluoxetine 10 mg PO daily
Education: Discussed social anxiety management, cognitive behavioral therapy, gradual exposure techniques, and medication compliance.
Chart 11
Age: 47
Race: Asian
Gender: Male
Chief Complaint: I hear voices sometimes.
HPI: Patient reports auditory hallucinations, paranoia, social withdrawal, and poor sleep for several months. Denies command hallucinations or SI/HI.
CPT 9: 90837
CPT 10: 99215
ICD-9: 295.90
Medication: Risperidone 1 mg PO at bedtime
Education: Reviewed psychosis symptoms, medication adherence, importance of family support, crisis intervention resources, and follow-up care.
Chart 12
Age: 36
Race: Native American
Gender: Female
Chief Complaint: My mood changes quickly.
HPI: Patient reports unstable relationships, emotional outbursts, impulsive spending, and chronic feelings of emptiness. Denies current SI/HI.
CPT 9: 90834
CPT 10: 99214
ICD-9: 301.83
Medication: Aripiprazole 2 mg PO daily
Education: Discussed emotional regulation skills, dialectical behavioral therapy, medication monitoring, and coping strategies.
Chart 13
Age: 65
Race: White
Gender: Male
Chief Complaint: I forget things often.
HPI: Patient reports progressive forgetfulness, misplacing items, and difficulty remembering appointments over the past year. Family reports mild confusion at times.
CPT 9: 96116
CPT 10: 99214
ICD-9: 331.83
Medication: Donepezil 5 mg PO daily
Education: Reviewed memory support strategies, medication administration, caregiver support, home safety, and follow-up evaluations.
Chart 14
Age: 31
Race: Middle Eastern
Gender: Female
Chief Complaint: I cannot stop checking things.
HPI: Patient reports repetitive handwashing, checking locks multiple times daily, and intrusive thoughts interfering with daily functioning. Symptoms present for several years.
CPT 9: 90837
CPT 10: 99214
ICD-9: 300.3
Medication: Fluvoxamine 50 mg PO at bedtime
Education: Discussed obsessive-compulsive disorder symptoms, exposure response prevention therapy, medication side effects, and stress reduction techniques.
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