SOAP NOTE

Consent for treatment

Name:

DOB:

Minor:

Accompanied by:

Demographic:

Gender Identifier Note:

Chief Complaint

Reason for the visit, often in the patient’s words

History of Present Illness

Subjective information from the patient.

Description of what the patient wants to be seen for

Mood characteristics

Depression/Anxiety/Panic/Mood instability, etc

Tolerable/Not tolerable

Getting worse or better, if so when did this start

Any stressors that make the condition worse

Are the stressors internal or environmental

When did the patient start manifesting the mood characteristics

Pertinent past history if it pertains to current condition, but it should really only include what is currently happening with the patient.

Things that are exacerbating or alleviating symptoms

SI/HI

Include if the thoughts are passive or active

Intent

Plan

Access to what is needed to complete plan

If HI, do they have a target (consider duty to warn)

Hallucinations/Delusions

If having, what type

How long is it happening

If causing distress

Sleep

Trouble falling asleep

Staying Asleep

Daytime fatigue

Medications

Current medications related to current issue (Prescription, OTC, Supplements)

Side Effects

Effectiveness

Appetite

If patient has multiple issues, what does the patient view as the priority issue to manage

Are they seeing a therapist or any other resource for their current condition

Psychiatric History:

Age of onset

Previous Diagnoses

Past psychotropic history

Past Hospitalizations

Reason for hospitalization

Include dates

Length of stay

Suicide Attempt History

Dates

What they did to attempt

What triggered the attempt

Legal History

Dates

What arrested or in jail for

Trauma History

Physical, Emotional, Sexual or Event

What was the trauma

When did happen

Who performed the abuse if applicable

If they have dealt with the trauma

Substance Use History

Include Past and Present Use

Tobacco

Alcohol

Marijuana

Illicit Substance (ask what substances specifically)

Ask if this has been a problem for the patient in the past and how they have coped with it if they quit

Can also include caffeine if want to

Social History

Include

Born and Raised

Parents married, divorced, separated

Siblings

Childhood (developmental, emotional)

Highest level of education

Employment status (if unemployed, is patient looking for a job)

Relationship status

Children

Living Situation

Social Support

Medical History

Surgical History

Current Medications (All Medications, even if not psychotropics)

Allergies

Family History (Medical and Mental Health)

Review of Systems

OBJECTIVE

Vital signs

Labs

Test results e.g EKGs

Mental Status Exam

Assessment

Screening Tool results if any used

Risk Assessment

Diagnoses (Justify diagnosis and differential diagnosis using DSM -5)

Current

Rule Out

Differential

Plan of Care (This section should be very detailed. I will place an example here. You can modify as you see fit)

The patient denies suicidal or homicidal ideation including intention, method or plan. There are no other safety concerns. This individual is appropriate to be followed in the outpatient clinic. The writer reviewed all of the intake forms as well as the mental health screens. This individual did sign consent forms for treatment as well as the privacy and financial policies.

Regarding medications, medications were discussed in depth at this appointment. We will continue Lexapro 20mg daily for depression and anxiety. We will initiate Abilify 2mg daily at bedtime to augment Lexapro and help with treatment resistant depression, propranolol 10mg TID PRN for anxiety. If patient does not receive relief with Abilify alone, we may consider switching to Effexor at next appointment and cross-titrating with Lexapro. Patient agreed to cut back on drinking, but if continues to have issues with drinking will discuss treatment strategies at next appointment. Risk, Benefits and alternatives regarding medications were discussed with the patient and patient is agreeable to treatment plan. Medications prescribed through ePrescribing.

Writer discussed the importance of psychotherapy related to treatment, patient was referred to an onsite therapist for psychotherapy and CBT.

Patient was instructed to exercise regularly, utilize sleep hygiene, avoid alcohol, illicit substances, and caffeine. Patient advised to practice mindfulness strategies

Writer is recommending patient continue to follow-up with PCP regarding any medical conditions

Patient advised to call 911 or report to emergency room if there is a medical or mental health emergency

Recommend that patient follow-up in 2 weeks

Additional resources were provided to this patient to include handouts with some basic coping skills for when the patient has anxiety, sleep hygiene practices and information on the therapies recommended.

Labs were also ordered at this appointment to include a CBC with Diff, CMP, Lipids, Vitamin B12, Vitamin D, Hemoglobin A1C. May consider additional labs to include UDS, GGT level, Iron Panel if hemoglobin low

Discussions of FDA-approved medications or indication of "off-label" usage are important for treatment plans.

For females, discussion on the effects medication has on birth control, pregnancy, and sexual dysfunction

For males, discussion on sexual dysfunction

Under 25 years old Black box warning for SSRI/SNRI

Billing Codes

Time Spent with patient, therapy time, date

Your name and title