Unit 4-Adult Psychiatric Initial Interview-Assessment. Due 1-31-24. NU672 Counseling and Psychotherapy

Initial Psychiatric Interview/SOAP Note Template

There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to develop your style of SOAP in the psychiatric practice setting.

Criteria Clinical Notes

Informed Consent Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy

treatment. Verbal and Written consent obtained. Patient the ability/capacity to

respond and appears to the risk, benefits, and (Will review additional consent

during treatment plan discussion) Subjective Verify Patient

Name: Corey (from case #2) DOB: 16 y.o (specific DOB not provided in video)

Minor: Accompanied by: Mother

Demographic: Caucasian

Gender Identifier Note: male

CC: “Mom’s always on me for everything. She’s the reason I’m here.” “I wanna play sports so that’s why I’m here.”

HPI: Corey is a 16 y.o Caucasian male seen today in office accompanied by his mother. Patient has no significant past medical or psychiatric history. He lives at home with his mother father and older sister, when she is home from college. Collateral information received from both patient and his mother. Patient is currently a high school sophomore. Both he and his mother report a decline in performance at school. Patient states his grade have worsened over the past year. He reports difficulty concentrating, note taking and paying attention in class. Patient states he must be redirected to stop “doodling and talking” in class. Patient also describes difficulty with math, reading and writing due to an inability to sit still to complete tasks. Patient reports difficulty falling asleep at night. Corey also verbalizes periods of frustration with his mother because she is “on me for everything” and he believes his mother is frustrated with him because she thinks he is “bad on purpose” Patient does state he enjoys playing sports but due to his poor performance in school he is unable to participate in extracurricular activities. Patient reports this as the driving force to seek assistance currently.

Pertinent history in record and from patient: no previous psychiatric treatment

Verify Patient: Name, Assigned identificati on number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo.

Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview.

HPI:

, Past Medical and Psychiatric History, Current Medications, Previous Psych Med trials, Allergies.

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Social History, Family History. Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…”

During assessment: Patient describes their mood as sad that he is disappointing his mother and cannot play sports.

Patient self-esteem appears fair, no reported feelings of excessive guilt, no reported anhedonia, does report difficulty falling asleep, does not report change in appetite, does not report libido disturbances, does not report change in energy, Does report decreased concentration and memory for over a year.

Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. Patient does not report excessive fears, worries or panic attacks. Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a characterological nature.

SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors.

Allergies: NKDFA. (medication & food)

Past Medical Hx: Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury. Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C. Surgical history no surgical history reported

Past Psychiatric Hx: Previous psychiatric diagnoses: none reported. Describes course of illness.

Previous medication trials: none reported.

Safety concerns: History of Violence to Self: none reported History of Violence to Others: none reported Auditory Hallucinations: none reported Visual Hallucinations: none reported

Mental health treatment history discussed: History of outpatient treatment: not reported Previous psychiatric hospitalizations: not reported Prior substance abuse treatment: not reported

Trauma history: Client does not report history of trauma including abuse, domestic violence, witnessing disturbing events.

Substance Use: Client denies use or dependence on nicotine/tobacco products. Client does not report abuse of or dependence on ETOH, and other illicit drugs.

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Current Medications: No current medications. (Contraceptives): Supplements:

Past Psych Med Trials: N/A

Family Medical Hx:N/A

Family Psychiatric Hx: N/A Substance use N/A Suicides N/A Psychiatric diagnoses/hospitalization N/A Developmental diagnoses N/A

Social History: Occupational History: currently unemployed. Denies previous occupational hx Military service History: Denies previous military hx. Education history: current 10th grade high school student Developmental History: no significant details reported. (Childhood History include in utero if available) Legal History: no reported/known legal issues, no reported/known conservator or guardian. Spiritual/Cultural Considerations: none reported. ROS: Constitutional: No report of fever or weight loss. Eyes: No report of acute vision changes or eye pain. ENT: No report of hearing changes or difficulty swallowing. Cardiac: No report of chest pain, edema or orthopnea. Respiratory: Denies dyspnea, cough or wheeze. GI: No report of abdominal pain. GU: No report of dysuria or hematuria. Musculoskeletal: No report of joint pain or swelling. Skin: No report of rash, lesion, abrasions. Neurologic: No report of seizures, blackout, numbness or focal weakness. Endocrine: No report of polyuria or polydipsia. Hematologic: No report of blood clots or easy bleeding. Allergy: No report of hives or allergic reaction. Reproductive: No report of significant issues. (females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…)

Objective Vital Signs: Stable Temp: BP: unknown HR: unknown R: unknown

This is where the “facts” are located. Vitals, **Physical Exam (if performed, will not

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be performed every visit in every setting) Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results.

O2: unknown Pain: unknown Ht: unknown Wt: unknown BMI: unknown BMI Range: unknown LABS: Lab findings WNL Tox screen: Negative Alcohol: Negative HCG: N/A

Physical Exam: MSE: Patient is cooperative and conversant, appears without acute distress, and fully oriented x 4. Patient is dressed appropriately for age and season. Psychomotor activity appears restless and fidgety. Presents with eye contact, affect - , ,

with reported mood of “ok”. Speech: , rate,

volume/tone with .

TC: content elicited, suicidal ideation and homicidal ideation.

Process appears , , .

Cognition appears grossly intact with attention span & concentration

and average fund of knowledge. Judgment appears . Insight appears

The patient is able to articulate needs, is motivated for compliance and adherence to medication regimen. Patient is willing and able to participate with treatment, disposition, and discharge planning.

Assessment DSM5 Diagnosis: with ICD-10 codes

Dx: - F90.2 Attention deficit hyperactivity disorder , combined type Dx: - Dx: -

Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible),

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including obstacles to treatment.

Informed Consent Ability

Patient the ability/capacity appears to respond to psychiatric

medications/psychotherapy and appears to the need for medications/psychotherapy

and willing to maintain adherent.

Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment.

References: Epocrates Web. (n.d.). Online.epocrates.com. Retrieved May 26, 2021, from https://online.epocrates.com/diseases/14231/Attention-deficit-hyperactivity-disorder-in- children/Diagnostic-Approach

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