Mental Health SOAP Notes Examples

Mental Health SOAP Notes Examples

Here’s a Mental Health SOAP Notes Examples for PMHNP, includes all the sections such as Subjective, Objective, Assessment and Plan

Student Name: [Your Name] College of Nursing-PMHNP, Walden University PRAC 6665: PMHNP Care Across the Lifespan I Faculty Name: [Faculty Name] Assignment Due Date: [Due Date]

Subjective

Subjective: CC (chief complaint): 42-year-old Caucasian male. “The judge ordered me to get a psych eval after receiving a charge for aggravated assault. I defended myself when someone pulled a gun out on me. I don’t have any issues mentally. I should be able to defend myself. I don’t deserve what happened.” Patient reports nightmares and sleep disturbances since being released from jail. He states, “I’m doing better now.” Patient experienced trauma from losing his best friend (dog) while incarcerated. He reports getting only 2-3 hours of sleep, difficulty returning to sleep, racing thoughts, and “tons of anxiety.”

HPI: Patient was incarcerated for five months following an aggravated assault charge. He expresses feeling wronged by the legal system. States, “It’s really scary there, and I’ve never seen anything like it before.” Family members have suggested he may have PTSD following his incarceration.

Substance Current Use: Patient reports cessation of alcohol six months ago and stopped using marijuana due to increased anxiety. Denies any other illicit drug use.

Medical History:

• Current Medications: None
• Allergies: None reported
• Reproductive Hx: N/A

Objective

ROS:

• GENERAL: No fevers, sweats, shakes, chills or change in weight
• HEENT: 20/20 vision, no report of vision changes. No epistaxis or tinnitus
• SKIN: Denies rashes or itching
• CARDIOVASCULAR: No edema, chest pain, or palpitations
• RESPIRATORY: Denies shortness of breath, cough, wheezing, or sputum
• GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood
• GENITOURINARY: Denies frequency, nocturia, dysuria, or hematuria
• NEUROLOGICAL: Denies any focal neurologic complaints
• MUSCULOSKELETAL: No joint swelling, stiffness, pain or myalgias
• HEMATOLOGIC: No abnormal prolonged bleeding or bruising
• LYMPHATICS: No enlarged nodes
• ENDOCRINOLOGIC: Denies excessive thirst, urination, heat or cold intolerance, diabetes or thyroid disease

Objective: Diagnostic results: No labs, X-rays, or other diagnostics at this time. Will order comprehensive metabolic panel, CBC, and TSH before next appointment to rule out medical causes of symptoms.

Assessment: Mental Status Examination:

Assessment:

Mental Status Examination:

• Appearance: Neatly groomed, appropriately dressed in casual attire
• Appears stated age: Yes, looks consistent with 42 years
• Gait: Normal, steady without assistance
• Behavior: Calm but occasionally restless when discussing incarceration
• Eye contact: Fair, intermittent when discussing traumatic events
• Speech: Rate – normal, Tone – normal, occasionally becomes louder when discussing perceived injustice
• Mood: Euthymic with underlying irritability, “I’m fine but this is all unfair”
• Affect: Congruent with content, full range, becomes tense when discussing jail experience
• Thought process: Linear, goal-directed
• Thought content: Preoccupied with a legal situation, no delusions
• Suicide ideation: None; denies past attempts or current thoughts
• Homicidal ideation: None, though expresses frustration about the assault incident
• Perceptual disturbances: None (denies auditory or visual hallucinations)
• Insight: Good regarding the legal situation, fair regarding potential mental health impact
• Judgment: Good in an interview setting; history suggests impulsivity under stress
• Fund of knowledge: Good, demonstrates awareness of current events
• Memory: Good, recalls recent and remote events without difficulty
• Cognition: Alert, oriented to self, place, situation, and date. No evidence of cognitive impairment.

Diagnostic Impression:

1. Posttraumatic Stress Disorder (F43.10)
   • Criterion A: Exposure to actual threat of death during assault incident, witnessed traumatic events in jail
   • Criterion B: Recurrent nightmares, intrusive memories of incarceration
   • Criterion C: Avoidance of thoughts/feelings related to incarceration
   • Criterion D: Negative alterations in cognition/mood (feeling wronged by system)
   • Criterion E: Hyperarousal (sleep disturbance, anxiety, hypervigilance)
   • Criterion F: Duration > 1 month since release
   • Criterion G: Causes significant distress in social/occupational functioning
   • Criterion H: Not attributable to substance use or medical condition
2. Adjustment Disorder with Anxiety (F43.22)
   • Emotional/behavioral symptoms developed in response to identifiable stressors (legal issues, incarceration)
   • Symptoms developed within 3 months of stressors
   • Clinically significant distress exceeding what would be expected
   • Symptoms not part of normal bereavement
   • Once the stressor has terminated, symptoms persist for less than 6 months
3. Rule out Substance-Induced Anxiety Disorder (F19.980)
   • History of alcohol and marijuana use
   • Current anxiety symptoms could be influenced by recent cessation
   • Need to monitor for withdrawal symptoms or cravings

Differential Diagnoses:

1. Generalized Anxiety Disorder (F41.1)
   • Less likely as anxiety appears specifically related to a traumatic experience
   • Will monitor for generalization of anxiety symptoms beyond trauma-related contexts
2. Major Depressive Disorder (F32.9)
   • Some symptoms overlap (sleep disturbance, anhedonia)
   • Currently lacks core depressive symptoms (persistent low mood, significant appetite changes)
   • Will monitor for development of depressive symptoms over time
3. Insomnia Disorder (G47.00)
   • Sleep disturbance appears secondary to PTSD symptoms
   • Will reassess if sleep symptoms persist after addressing primary diagnosis

Psychological Testing Considerations:

• Recommend PTSD Checklist for DSM-5 (PCL-5) to quantify symptom severity
• Consider Beck Anxiety Inventory (BAI) to measure anxiety symptoms
• Pittsburgh Sleep Quality Index (PSQI) to assess sleep disturbance patterns

Psychosocial Assessment:

• Limited social support network following incarceration
• Grief over loss of pet (significant attachment figure)
• Financial stressors due to legal fees and potential employment difficulties
• Housing appears stable at present
• No current substance abuse but history suggests risk for relapse under stress

Plan

Case Formulation and Treatment Plan:

1. Diagnosis: Primary – Posttraumatic Stress Disorder (F43.10)
2. Psychopharmacology:
   • Recommend trial of Prazosin 1mg QHS for nightmares, titrating by 1mg weekly as needed up to 15mg based on response and tolerability
   • Monitor for side effects: hypotension, dizziness, headache
   • Start Sertraline 25mg daily for 1 week, then increase to 50mg daily for anxiety and PTSD symptoms
   • Target dose: 50-200mg daily based on symptom response
   • Monitor for side effects: GI disturbance, sexual dysfunction, activation
   • Avoid benzodiazepines due to history of substance use and risk of dependence
   • Consider trazodone 50-100mg QHS for sleep if prazosin insufficient for insomnia
3. Psychotherapy:
   • Trauma-focused Cognitive Behavioral Therapy (TF-CBT), weekly sessions for 12-16 weeks
   • Components to include:
     • Psychoeducation about trauma responses
     • Relaxation training (diaphragmatic breathing, progressive muscle relaxation)
     • Cognitive restructuring of maladaptive thoughts about traumatic events
     • Gradual exposure to trauma memories
   • Sleep hygiene education and stimulus control techniques for insomnia
   • Referral to support group for individuals reintegrating after incarceration
   • Consider EMDR (Eye Movement Desensitization and Reprocessing) as an alternative if TF-CBT not effective
4. Patient Education:
   • Provide psychoeducation on PTSD symptoms and normal responses to trauma
   • Discuss the importance of medication adherence and potential side effects
   • Teach specific relaxation techniques (provide written materials):
     • 4-7-8 breathing technique
     • Guided imagery scripts
     • Mindfulness meditation exercises
   • Educate on sleep hygiene principles:
     • Consistent sleep/wake times
     • Avoiding stimulants after noon
     • Creating bedtime routine
     • Limiting screen time before bed
5. Safety Planning:
   • No current SI/HI, but will monitor for the emergence of suicidal thoughts
   • Provided crisis hotline information: National Suicide Prevention Lifeline (988)
   • Discussed coping strategies for managing anger in triggering situations:
     • Time-out procedures
     • Anger management techniques (STOP method)
     • Identifying early warning signs of escalation
   • Create a written safety plan including:
     • Warning signs
     • Internal coping strategies
     • Social contacts for distraction
     • Professional contacts
     • Ways to make environment safe
6. Follow-up and Monitoring:
   • Schedule return appointment in 2 weeks to assess medication response
   • Baseline labs to include:
     • Complete Metabolic Panel
     • Complete Blood Count
     • Thyroid Stimulating Hormone
     • Urine drug screen (with consent)
   • Coordinate care with therapist and probation officer (with patient consent)
   • Periodic use of PCL-5 to track symptom improvement
   • Monitor vital signs at each visit while titrating medications
   • Assess for emergence of depressive symptoms or substance use relapse
7. Psychosocial Interventions:
   • Referral to legal aid services for ongoing legal issues
   • Vocational rehabilitation services if employment affected
   • Pet therapy or support for grief over lost pet
   • Community reintegration resources
   • Stress management techniques specific to legal system navigation
8. Treatment Goals (to be developed collaboratively with patient): Short-term (1-3 months):
   • Reduce nightmares from nightly to ≤2 times per week
   • Improve sleep duration from 2-3 hours to 6+ hours per night
   • Develop and practice 3 effective coping skills for anxiety
   Long-term (3-6 months):
   • Achieve remission of PTSD symptoms (PCL-5 score reduction of 10+ points)
   • Successfully reintegrate into community functioning
   • Develop healthy stress management techniques
   • Maintain sobriety from substances
9. Prognosis:
   • Guarded to fair, dependent on:
     • Medication adherence
     • Engagement in psychotherapy
     • Resolution of legal stressors
     • Development of coping skills
     • Avoidance of substance use relapse
10. Potential Barriers to Treatment:
    • Stigma around mental health treatment, especially in context of legal evaluation
    • Potential medication side effects affecting adherence
    • Ongoing legal stressors exacerbating symptoms
    • Limited insight into mental health needs
    • Financial constraints for treatment
11. Contingency Planning:
    • If no response to initial SSRI, consider switch to alternative (e.g., Paroxetine)
    • If partial response, consider augmentation strategies
    • If significant side effects to Prazosin, consider alternative for nightmares (e.g., low-dose Quetiapine)
    • If therapy attendance issues, explore barriers and consider telehealth options

This expanded assessment and treatment plan provides a comprehensive approach addressing the biological, psychological, and social aspects of the patient’s presentation, with specific interventions tailored to his unique situation and symptoms

PRECEPTOR VERIFICATION: I confirm the patient used for this assignment is a patient who was seen and managed by the student at their Meditrek-approved clinical site during this quarter course of learning.

Preceptor signature: ________________________________________________________ Date: ________________________

References

1. American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text revision). https://doi.org/10.1176/appi.books.9780890425787
2. Sadock, B. J., Sadock, V. A., & Ruiz, P. (2021). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (12th ed.). Wolters Kluwer.
3. Stahl, S. M. (2021). Stahl’s essential psychopharmacology: Prescriber’s guide (7th ed.). Cambridge University Press.
4. VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. (2022). https://www.healthquality.va.gov/guidelines/MH/ptsd/