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PMHNP Problem Focused SOAP Note

(Use this template for this Assignment)

Demographic Data

• Patient age and Patient’s gender identity
• MUST BE HIPAA compliant.

Subjective

Chief Complaint (CC):

• Place the patient’s CC complaint in Quotes

History of Present Illness (HPI):

 

 

• • Reason for an appointment today.
  • The events that led to hospitalization or clinic visits today.
  • Include symptoms, relieving factors, and past compliance or non-compliance with medications
  • Any adverse effects from past medication use
  • Sleep patterns – number of hours of sleep per day, early wakefulness, not being able to initiate sleep, not able to stay asleep, etc.
  • Suicide or homicide thoughts present
  • Any self-care or Activity of Daily Living (ADL) such as eating, drinking liquids, self-care deficits or issues noted?
  • Presence/description of psychosis (if psychosis, command or non-command)

Problem Focused SOAP Note

Past Psychiatric History (PSH):

• • Past psychiatric diagnoses
  • Past hospitalizations
  • Past psychiatric medications use
  • Any non-compliance issues in the past?
  • Any meds that didn’t work for this patient?

Family History of Psychiatric Conditions or Diagnoses:

• • Mother/father, siblings, grandparents, or direct relatives

Social History: 

• • Include nutrition, exercise, substance use (details of use), sexual history/preference, occupation (type), highest school achievement, financial problems, legal issues, children, history of personal abuse (including sexual, emotional, or physical).

Allergies:

• • to medications, foods, chemicals, and other.

Review of Systems (ROS) (Physical Complaints):

• • Any physical complaints by body system? (Respiratory, Cardiac, Renal, etc.)

Objective

Mental Status Exam:

• • This is not physical exam.
  • Mini-Mental Status Exam (MMSE) – Full exam

Assessment (Diagnosis)

Differentials

• Two (2) differential diagnoses with ICD-10 codes.
• Must include rationale using DSM-5 Criteria (Required)
• Why didn’t you pick these as a major diagnosis?

Working Diagnosis

• Final or working diagnosis (1), with ICD-10 code.
• Must include rationale using DSM-5 criteria required – Which symptoms/signs in the DSM-5 the patient matches mostly)

Problem Focused SOAP Note

Plan

Treatment Plan (Tx Plan):

• Pharmacologic: Include full information for each medication(s) prescribed,
• Refill Provided: Include full information for each medication(s) refilled,

Patient Education:

• including specific medication teaching points,
• Was risk versus benefit of current treatment plan addressed for meds or treatment,
• Risk versus benefit of non-FDA approved for working diagnosis – Off-label use of medication education to patient addressed?

Prognosis:

• Make Decision for prognosis: Good, Fair, Poor
• Provide brief statement lending support for or against the decided prognosis.

Therapy Recommendations:

• Type(s) of therapy recommended.

Problem Focused SOAP Note

Referral/Follow-up:

• Did you recommend follow-up with Psychiatrist PCP or other specialist or healthcare professionals?,
• When is the subsequent follow-up?,
• Include rationale for the F/U recommendation or referral.,

 Reference(s):

• Include American Psychological Association (APA) formatted references.
• Include a reference from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) or the accompanying Desk Reference of Diagnostic Criteria from DSM-5.
• Minimum 2 references are required.

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