Instructions
Each week students will choose one patient encounter to submit a Follow-up SOAP note for review.
Follow the rubric to develop your SOAP notes for this term.
The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.
Note: Grades of Incomplete on this assignment will result in a clinical failure.
All work should be original and submitted as a Word document unless otherwise indicated in the assignment instructions. ALL assignments need to be APA 7 format and accompanied title page in APA 7th edition format in order that the work would be properly identified for the student, the course, and the assignment. Work submitted without a title page will receive a grade of 0.
Instructions
Each week students will choose one patient encounter to submit a Follow-up SOAP note for review.
Follow the rubric to develop your SOAP notes for this term.
The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.
Note: Grades of Incomplete on this assignment will result in a clinical failure.
All work should be original and submitted as a Word document unless otherwise indicated in the assignment instructions. ALL assignments need to be APA 7 format and accompanied title page in APA 7th edition format in order that the work would be properly identified for the student, the course, and the assignment. Work submitted without a title page will receive a grade of 0.
Template example:
Your SOAP note should be on a patient you are performing a new psychiatric evaluation with since we want psychiatric history and other history obtained.
Consent for treatment
Template:
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