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. Refer to the Psychiatric SOAP Note PowerPoint for further detail about each of these sections.
Criteria Clinical Notes Subjective Include chief complaint, subjective information from the patient, names and relations of others present in the interview, and basic demographic information of the patient. HPI, Past Medical and Psychiatric History, Social History. Objective This is where the “facts” are located. Include relevant labs, test results, vitals, and Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…” Include MSE, risk assessment here, and psychiatric screening measure results. Assessment Mini mental assessment goes here, normal for patient
ICD-10 code will be a 25 minute visit Diagnosis: ADHD Test performed is ADHD screening
Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes,
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treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment. Plan
-Start Adderall 5 mg PO daily, possible increase of dose to 10 mg depending on patient’s response to the treatment -EKG and basic labs, CBC, BMP to have a baseline level -Bring patient back in 2 weeks to follow up and see if treatment is effective. -Recommend relaxation techniques at night time and/or use Magnesium for anxious mood at night
Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options and complimentary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment.
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Certainly! Below is an example of a Psychiatric SOAP Note using the template provided:
—
**Subjective:**
**Chief Complaint:** “I can’t focus on my work and I’m always distracted.”
**HPI (History of Present Illness):**
The patient is a 25-year-old male who presents with difficulties in maintaining attention and concentration for the past 6 months. He reports that these symptoms are impacting his performance at work and his daily life activities. He feels restless, frequently loses things necessary for tasks, and is easily distracted by extraneous stimuli. He denies any significant mood changes, hallucinations, or delusions.
**Past Medical and Psychiatric History:**
– Past Medical History: No significant medical history.
– Past Psychiatric History: None reported.
**Social History:**
– Lives alone, works as a software engineer.
– No history of substance abuse.
– No significant family history of psychiatric disorders.
**Others Present:** None.
**Basic Demographics:** 25-year-old male, single, employed.
—
**Objective:**
**Vitals:**
– BP: 120/80 mmHg
– HR: 72 bpm
– Temp: 98.6°F
– RR: 16 breaths/min
**Review of Systems (ROS):**
– General: No weight loss, fever, or fatigue.
– HEENT: No visual disturbances, no hearing loss.
– Respiratory: No shortness of breath.
– Cardiovascular: No chest pain, palpitations.
– Gastrointestinal: No nausea, vomiting.
– Neurological: No headaches, no seizures.
– ROS noncontributory.
**Mental Status Examination (MSE):**
– Appearance: Well-groomed, casually dressed.
– Behavior: Cooperative, good eye contact.
– Speech: Normal rate and volume.
– Mood: “Frustrated.”
– Affect: Appropriate to context.
– Thought Process: Logical and goal-directed.
– Thought Content: No delusions, no hallucinations.
– Cognition: Alert and oriented to person, place, and time.
– Insight and Judgment: Fair.
**Risk Assessment:**
– No current suicidal or homicidal ideation.
– No history of self-harm.
**Psychiatric Screening Measure Results:**
– ADHD Screening: Positive for symptoms consistent with ADHD.
—
**Assessment:**
**Mini Mental Status Exam:**
– Normal for patient.
**Diagnosis:**
– Primary: Attention-Deficit/Hyperactivity Disorder (ADHD), Inattentive Type
– ICD-10 Code: F90.0
**Differentials:**
– Generalized Anxiety Disorder (GAD)
– Major Depressive Disorder (MDD)
– Substance Use Disorder
—
**Plan:**
**Medications:**
– Start Adderall 5 mg PO daily. Monitor for effectiveness and possible side effects. Consider increasing dose to 10 mg after 2 weeks if no significant improvement.
**Lab Work:**
– Order EKG and basic labs (CBC, BMP) to establish baseline levels before starting stimulant medication.
**Follow-Up:**
– Schedule follow-up appointment in 2 weeks to assess response to treatment and make necessary adjustments.
**Non-Pharmacological Recommendations:**
– Recommend relaxation techniques for night time to help with anxious mood. Consider using Magnesium supplements if anxiety persists.
**Referrals:**
– Referral to a psychologist for cognitive-behavioral therapy (CBT) to address attentional issues and develop coping strategies.
**Patient Education:**
– Discuss potential side effects of Adderall, importance of adherence to medication, and strategies for improving concentration and organizational skills.
**Next Appointment:**
– Follow up in 2 weeks to evaluate treatment efficacy and patient’s overall progress.
—
This comprehensive plan addresses the identified ADHD diagnosis and includes both pharmacological and non-pharmacological strategies tailored to the patient’s needs.
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