SOAP 2

Purpose: To record information from the patient, family members, friends, other data bases, other professionals (nurses, physicians, labs, X-ray, Etc), in order to accurately ascertain the information which you need to know about the patient and their disease process(es), so that you can make an accurate diagnosis and provide advice on the most appropriate treatment. The written record also provides a means of communication between you and your professional colleagues. It should be written in a manner which allows the reader to “see” what you observed, performed, discussed and plan to do for and with the patient. SOAP notes are generally done as a follow up after an initial H & P (Psychiatric evaluation) has been done.

Name of Patient:

Date of Service:

S: Subjective information of interest from patient

O: Objective clinical information of interest you observe and hear; Mental Status Exam (MSE)

A: DSM-5 diagnosis(es) and specifiers supported by clinical/historical information with ICD-code(s)

P: Plan of care including medications (trade/generic name, delivery type, dose, route, timing, length of prescription, # of refills), psychotherapy, medication education, crisis planning, and recommendations for next scheduled appointment.

Signature/credentials

*Each SOAP Note submitted after the due date will be penalized five (5) points per day, including weekends.

Syllabus 2016-2017

SOAP NOTE FORMAT/EXAMPLE: (Note: This example is not exhaustive and yours must include additional data such as elaboration of rationale, neurobiology, or other information important for an academic exercise but not necessarily appropriate for a clinical document in practice)

PSYCHIATRIC PROGRESS NOTE (SOAP)

NAME: Doe, John DATE: 05/1/2014

Subjective: CC: “I was in the hospital”. John is seen today as a status post hospitalization visit. He was hospitalized at from 04/26/14 to 04/30/14. He was apparently admitted for increased agitation and aggression, making threats toward his mother and his niece, with whom he had been living. John states that he does not believe he had been taking his medications correctly, but he also acknowledges that there was increased stressors at the time of hospitalization with his mother and his niece. It is not clear how long John had been living with his mother and niece. The last time he was seen at this clinic was in March of 2010 and he was a resident of Bellvue Personal Care Home. He now resides back at Bellvue Personal Care Home after discharge. John was stabilized and then discharged on his previous medication regimen. He was given a diagnosis of Chronic Paranoid Schizophrenia. However, John appears to have a significant mood component and has been diagnosed with Schizoaffective Disorder, which will continue to be his working diagnosis. John also states that he has quit smoking. He has not smoked in six days and plans to continue abstinence. His sleep, appetite, and weight remain stable.

Objective MSE: The patient is casually dressed and groomed. He looks very good today. He has good skin color. He is alert. He appears to be in good spirits. He makes good eye contact. He is calm and cooperative. Speech is regular in rate and tone, relevant, with some latency of response. Thoughts appear to be goal directed. He relates his mood as “good”. Affect is restricted. He denies any mood lability or instability, nor is there any noted. There is no evidence of any delusional thinking. There is no evidence of any perceptual disturbances. There is no evidence any suicidal or homicidal ideation and he denies same. He is alert and oriented X three.

Assessment:

Schizoaffective Disorder, Nicotine Use Disorder, Panic Disorder with Agoraphobia, Mild Intellectual Disability,Peptic Ulcer Disease; Gastritis; Hyperlipidemia;Obesity; Type II Diabetes; Early Diabetic Retinopathy;Disc Disease; Abnormal Tongue Movements; History of Thyroid Disease;Recent hospitalization and Housing issues

Current Medications:

a. Geodon 80 mg, po bid

b. Clonazepam 1 mg po qid

c. Fluoxetine 40 mg one po q day

d. Lithium Carbonate 300 mg, three tablets po q h.s.

Plan:

Continue with John’s current medication regimen. He has been doing well since discharge. He relates that he has been getting along with everyone at Bellevue. He has not had any further problems with anger, aggression, or agitation. During his previous residence at Bellevue, he was somewhat disgruntled and was seeking different housing; however, it appears that once than happened and he moved in with his mother his stressors increased and he destabilized. He is working with his caseworker to find alternative housing that would be appropriate. He will also continue in outpatient therapy with. John verbalizes understanding of, and is in agreement with, this treatment plan. He is encouraged to contact this office with further questions or concerns. He will be return to the office in four weeks for reevaluation, or sooner, as needed.

SOAP Grading sheet