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Initial Psychiatric Interview SOAP Note Template Comprehensive Nursing Paper Sample
There are different ways to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note. This is a template that is meant to guide you as you continue developing your SOAP style in the psychiatric practice setting. (Initial Psychiatric Interview SOAP Note Template Comprehensive Nursing Paper Sample)
| Criteria | Clinical Notes |
| Informed Consent | Informed Consent Informed consent was obtained from the patient about the psychiatric interview process and the anticipated psychiatric /psychotherapy treatment.(Initial Psychiatric Interview SOAP Note Template Comprehensive Nursing Paper Sample) Both verbal and written consent was secured, and the 72- year old patient has the ability and capacity to respond and appears to understand the risk and the benefits and has duly signed the Informed Consent form that follows(Initial Psychiatric Interview SOAP Note Template Comprehensive Nursing Paper Sample) . Informed Consent Form I …………………… understand that the information availed in this evaluation remains confidential and will not be revealed to any individual or organization without my written permission. (The revelation is available in the office or maybe completed with any person whom you desire to give access, and then availed to this clinic) The only exceptions to this release policy are rare scenarios where you – the patient are required by law to release information whether my permission has been granted or not. (Initial Psychiatric Interview SOAP Note Template Comprehensive Nursing Paper Sample)These exceptions are; If there exists evidence of physical / and or sexual abuse of children or abuse to the elderly, If you judge that I am at risk of harming myself or another person, and If the court subpoenas my records. If any of the above situations arise, I expect you would attempt to discuss your intentions with me before an action is taken and that you would limit the disclosure of any confidential information to the minimum requirement to ensure safety.(Initial Psychiatric Interview SOAP Note Template Comprehensive Nursing Paper Sample) I understand that if the Psychiatric facility considers that more or alternative testing is required, the facility will describe the reasons for the said testing and will equally advise me of any extra costs that may accrue. (Initial Psychiatric Interview SOAP Note Template Comprehensive Nursing Paper Sample) I understand that It is within my ambit to discontinue the evaluation process at any time. Be that as it may, I also understand that the facility may not manage to offer a feed of the test results if the testing is terminated and that I will still bear the cost of any testing, scoring, and evaluation time offered up to that specific point. By appending my signature below, I acknowledge that I consent to a psychological evaluation by this psychiatric facility, that I have been fully informed of the guidelines within the context of these evaluations and have read the entire content of the consent form, and that I agree to all of the payment arrangements outlined in the document. (Initial Psychiatric Interview SOAP Note Template Comprehensive Nursing Paper Sample) I fully understand my rights, responsibilities, and obligations as a client of the facility, and I freely agree to this assessment. ———————— ——— ————————— Client’s signature (Relationship with Client if below 14 years) Date Name in print ———————— ——— ————————— Parent’s signature (Optional if Client is above 14 years) Date Name in print ———————————– ———— —————————- Clinician’s Signature Date Name in Print |
| Subjective | Verify Patient Name: Patient Initials DOB: October, 1949 Minor: N/A Accompanied by: N/A Demographic: Elderly male. Gender Identifier Note: Male CC: I am depressed and do not have appetite for food. HPI: The healthcare staff examined the patient where the case was discussed and notes reviewed from the past few days. (Initial Psychiatric Interview SOAP Note Template Comprehensive Nursing Paper Sample) The healthcare team reviewed the meeting that is held three times every week. The patient continues to exhibit a depressed/dysphoric shut-down with a remarkable sign of not taking any food or drink sufficient to sustain his life healthily. This self-induced starvation necessitated the medical team to put the client on intravenous feeding. There is no need for the provider to engage the patient today or staff as he agreed to take the medication administered. It should not escape notice that while the patient refused to have his meals yesterday, he accepted to take a breakfast serving at the behest of the registered nurse.(Initial Psychiatric Interview SOAP Note Template Comprehensive Nursing Paper Sample) The resident dietician is aware of this patient’s case and has taken the necessary measures to ensure that the patient’s caloric intake is not compromised (Lang et al., 2015). The dietician recommends that the patient not be served non-nutritious beverages like black tea or coffee but get plenty of milk and fruit juices. The patient is also advised to participate in the light activity to stimulate his appetite. Most importantly, it has been observed that the patient’s depression is the main cause of his poor appetite, so it is expected that alleviating the symptoms of depression will directly impact improving his appetite. Pertinent history in record and from patient: has self-induced starvation necessitating the medical team to put the client on intravenous feeding. (Initial Psychiatric Interview SOAP Note Template Comprehensive Nursing Paper Sample) During assessment: Patient describes their mood as depressed/dysphoric shut-down with a remarkable sign of not taking any food or drink sufficient to sustain his life healthily. (Initial Psychiatric Interview SOAP Note Template Comprehensive Nursing Paper Sample) Patient self-esteem appears fair, with mild feelings of excessive guilt, no reported anhedonia, reports sleep disturbance, does report change in appetite, does not report libido disturbances, reported changes in concentration or memory, SI/ HI/ AV: Patient reports no suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, and denies inappropriate/illegal behaviors. Allergies: The patient reports he develops hives, rashes, and itching if penicillin-based medication is administered (Verified allergy on August 29, 2021).. (medication & food) Past Medical Hx: Medical history: Reports negative for 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: no reported past psychiatry history. Describes stable course of illness. Previous medication trials: no reported medication trials Safety concerns: History of Violence to Self: negative History of Violence to Others: negative Auditory Hallucinations: negative Visual Hallucinations:negative Mental health treatment history discussed: History of outpatient treatment: none reported Previous psychiatric hospitalizations: none reported Prior substance abuse treatment: none reported Trauma history: Client reports negative history of trauma including abuse, domestic violence, witnessing disturbing events. Substance Use: Client denies use or dependence on nicotine/tobacco products. Client denies t abuse of or dependence on ETOH, and other illicit drugs. (Initial Psychiatric Interview SOAP Note Template Comprehensive Nursing Paper Sample) Current Medications: Aripiprazole 15 mg HS Oral Last administered September 16, 2021, at 2200 hours. Initiated on September 16, 2021, at 2120 hours.Dextrose/Sodium chloride, 1000ml @ 70 mls/hr Q14H 18 min IV Last administered on September 17, 2021 at 1200 hours, stopped on September 17, 2021 at 2145 hours.Escitalopram Oxalate 15 mg Daily oral last administered on September 17, 2021, at 2145 hours, initiated on September 13, 2021, at 2140 hours. Magnesium hydroxide 30 mls every other day PRN constipation Started on June 30, 2021, at 0615 hoursNutritional formula 120 mls daily oral pudd Last Administered on September 15, 2021, at 2125 hours. Initiated August 50, 2021, at 2100 hoursTrazodone hydrochloride 50 mg qhs PRN oral insomnia Last administered on September 11, 2021, at 0841 hours. Initiated August 12, 2021 (Contraceptives): N/A Supplements: None reported Past Psych Med Trials: None reported Family Medical Hx: None reported Family Psychiatric Hx: Substance use Negative Suicides Negative Psychiatric diagnoses/hospitalization Negative Developmental diagnoses Normal developmental milestones were reported. Social History: Occupational History: currently not employed. Denies previous occupational hx Military service History: Denies previous military hx. Education history: completed HS and vocational certificate Developmental History: no significant details reported. (Childhood History include in utero if available) Legal History: Denies reported/known legal issues, no reported/known conservator or guardian. Spiritual/Cultural Considerations: none reported. ROS: Constitution: Patient complains of unsteady gait, general weakness, and failure to thrive. HEENTM: Denies experiencing any symptoms. Respiratory: Denies experiencing any symptoms.(Initial Psychiatric Interview SOAP Note Template Comprehensive Nursing Paper Sample) Cardiovascular: Denies experiencing any symptoms. GI/Abdominal: Denies experiencing any symptoms. GU: Reports urinary retention, admits having a Foley catheter. Musculoskeletal: Complaints of general weakness. Skin: Denies experiencing any symptoms. No skin infection signs are visible Psychiatric/Neurologic: Denies experiencing any symptoms. Endocrine: Denies experiencing any symptoms. Hematological /Lymphatic: Denies experiencing any symptoms. All other systems: Reviewed and determined to be non-contributory. (Initial Psychiatric Interview SOAP Note Template Comprehensive Nursing Paper Sample) |
| Verify Patient: Name, Assigned identification 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. Social History, Family History. Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…”(Initial Psychiatric Interview SOAP Note Template Comprehensive Nursing Paper Sample) | |
| Objective | Vital Signs: Stable Temp:98.3 BP:107/70 HR: 70 R:19 O2: Room air Pain:2/10 Ht:69.5 inches Wt:121.9lbs BMI:18.7 BMI Range: LABS: Lab findings WNL Tox screen: Negative Alcohol: Negative HCG: N/A Physical Exam: MSE: Evaluation type By complexity Appearance: Poor grooming despite being appropriately dressed for the occasion. Behavior/motor activity: The patient’s attitude varied from time to time. There were instances when the patient was unwilling to talk, attributable to either inability or unwillingness to talk. It is also likely that somatic stress or severe mood symptoms were a causative factor to the patient’s occasional irritability and negative behaviors. Musculoskeletal: One could observe that muscle strength and tone are significantly weakened. Gait/station: Found to be unstable / not tested. Mood: Constantly shakes his head to indicate a negative way. The patient also exhibited an anxious mood, although he could or was not willing to elaborate further. Affect Dysphoric, flat, and very limited in range. Similarly, the patient’s mood was sad and anxious and exhibited some mood/affect lability. The past week has essentially witnessed a depressed patient. Thought process/associations: comparatively linear and goal-directed.(Initial Psychiatric Interview SOAP Note Template Comprehensive Nursing Paper Sample) Thought content: There were signs of paranoid delusions together with somatic delusions. BH Attitude: See-sawed between being uncooperative with odd behavior, other times composed and polite, then uncooperative any time he had anxiety attacks. BH Orientation: Oriented to self, place, situation, and general timeframe. BH Attention/concentration: fair Insight: Ranged from fair to poor Judgment: Deemed fair but curtailed. BH Remote memory: considered fair BH short term memory: considered fair BH/intellectual /cognitive function: considered fair Language: Found to be spontaneous, at times with clear speech, with a tone assessed to be normal, but he could barely speak other times. Fund of knowledge: fair. Suicidal ideation: Patient denies current suicidal ideation, is negative for active plans or intent but has been exhibiting passive suicidal ideations going his dramatic statement provoking the healthcare to ‘kill me.’ Homicide ideation: Negative. (Initial Psychiatric Interview SOAP Note Template Comprehensive Nursing Paper Sample) |
| This is where the “facts” are located. Vitals, **Physical Exam (if performed, will not be performed every visit in every setting) Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results.(Initial Psychiatric Interview SOAP Note Template Comprehensive Nursing Paper Sample) | |
| Assessment | DSM5 Diagnosis: with ICD-10 codes Major depressive disorder recurrent episode with severe psychosis Plan: F33.3 According to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), a person must exhibit feelings of guilt or worthlessness, persistent low or depressed mood, lack of interest in pleasurable activities, poor concentration, and appetite changes. Additional symptoms include sleep disturbances, suicidal ideation, and psychomotor retardation. The provider must establish that the patient must exhibit five symptoms with a depressed mood or anhedonia leading to social or economic impairment (Bains, & Abdijadid, 2021). This patient has exhibited six of these symptoms, thus confirming MDD diagnosis. Anxiety Likewise, the patient exhibited other symptoms suggestive of existing comorbidity. The patient presented with excessive anxiety and worry accompanied by multiple themes that exceeded more than six months. The individual finds it challenging to control excessive worry, even in minor matters. Giacobe and Flint(2018) posit that the individual must exhibit somatic symptoms consistent with hyperarousal like irritability and insomnia, all present in the patient, thus confirming a generalized anxiety disorder. The patient is a 72-year-old man presenting with an affective disorder with several symptoms that suggest MDD. (Initial Psychiatric Interview SOAP Note Template Comprehensive Nursing Paper Sample) Other manifestations are the failure to thrive mindset and general anxiety that paralyzes the patient. He was admitted to GMPP for evaluation and subsequent stabilization. The internal medical team is expected to address the comorbidities even as the OT team carries out the cognitive and functional assessments. Furthermore, a social worker collaborating with the healthcare team will liaise with the patient’s family for collateral history, updates on the hospital course, and disposition. When this provider saw the patient on August 2m 2021, he had multiple symptoms indicative of paralyzing anxiety. During this time, the client reported that he could not talk while eating or feels cannot breathe, thus exacerbating his irritable and fluctuating moods. Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment.(Initial Psychiatric Interview SOAP Note Template Comprehensive Nursing Paper Sample) |
| 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), including obstacles to treatment. Informed Consent Ability(Initial Psychiatric Interview SOAP Note Template Comprehensive Nursing Paper Sample) | |
| Plan (Note some items may only be applicable in the inpatient environment) (Initial Psychiatric Interview SOAP Note Template Comprehensive Nursing Paper Sample) | Inpatient: Psychiatric. Admits to depression and dysphoric mood as per HPI.(Initial Psychiatric Interview SOAP Note Template Comprehensive Nursing Paper Sample) Estimated stay 3-5 days Safety Risk/Plan: Risk for harm to others is deemed low, the risk for suicide in the current setting low, as do risk for self-harm or self-mutilation. The medications included in the treatment plan were duly discussed, and informed consent was given. (Initial Psychiatric Interview SOAP Note Template Comprehensive Nursing Paper Sample) The patient is to continue his hospitalization for ongoing psychiatric evaluation and medication adjustment. The other reasons for his continued stay at the hospital are the unstable clinical manifestation of not eating, being too weak to walk, and psychotic delusions Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic: (Initial Psychiatric Interview SOAP Note Template Comprehensive Nursing Paper Sample) At first, the medication regimen from the hospital included Olanzapine 10mg HS + 5mg bid- prn and lorazepam 1mg bid(Simmons et al., 2016).To manage the MDD trazodone serotonin modulator was initiated to reinforce the escitalopram and SSRI(Ratheesh et al., 2017). To alleviate the symptoms of anxiety disorders, Bandelow et al. (2017), azapirone is prescribed. In summary, the current regimen for the patient consists of Aripiprazole 15mg qhs, Ativan 1mg, Bid before breakfast/dinner, Escitalopram 15mg, methylphenidate 5mg daily, and Mirtsazapine7.5mg qhs. Education, including health promotion, maintenance, and psychosocial needs Importance of adhering to the prescribed medication Discussed current tobacco use. NRT not indicated. Safety planning measures and strategies were outlined Discuss worsening status and when to contact office or report to ED Referrals: endocrinologist for diabetes Follow-up, including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit 4 weeks ☒ > 50% time spent counseling/coordination of care. (Initial Psychiatric Interview SOAP Note Template Comprehensive Nursing Paper Sample) Time spent in Psychotherapy 25 minutes Visit lasted 59 minutes Billing Codes for visit: 90837 -Psychotherapy XX XX XX ____________________________________________ NAME, TITLE Date: Click here to enter a date. Time: X |
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