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Initial Psychiatric SOAP Note Template-Comprehensive nursing paper sample
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. (Initial Psychiatric SOAP Note Template-Comprehensive nursing paper sample)
| Criteria | Clinical Notes |
| Informed Consent | I Patient X YZ have read and I understand the information provided. I have had the opportunity to ask questions. I understand that my participation is voluntary and that I have the freedom to withdraw at any time, without having to give a reason and without cost I have the capacity to respond and to the best of my ability do understand the risk, benefits and will review additional consent during the discussion on treatment plan.. I understand that I will be given a copy of this consent form. I voluntarily agree to take part in this interview.(Initial Psychiatric SOAP Note Template-Comprehensive nursing paper sample) |
| Subjective | Verify Patient Name:Patient XYZ DOB: 04//01/2021 Minor: Accompanied by: Demographic: Gender Identifier (Initial Psychiatric SOAP Note Template-Comprehensive nursing paper sample)Note: Female aged 59 years Married with 5 grown children CC: I have developed side effects after using Paxil 30mg per day over the last four months and therefore I wish to discontinue the medication. HPI: Patient reports having an increased appetite and added 7 pounds within the last four months accompanied by an increase in Hg1c of 1per cent age point. She also reports anorgasmia and excessive daytime sedation Pertinent history in record and from patient; Two years ago the patient suffered 2 major stressors when her firstborn child developed leukemia and the patients parents passed away. She experienced a major depressive episode that was untreated until recently. (Initial Psychiatric SOAP Note Template-Comprehensive nursing paper sample) During assessment: Patient describes her mod as depressed. Patient self-esteem appears to have a high self- esteem. She loves and accepts herself and believes in her abilities. She reports increased appetite and fatigue. She also admits having some sexual dysfunction. Current medication is Paxil 30mg/day to depression and oral hypoglycemic medication (glipizide 10 mg twice a day to manage her non- insulin dependent diabetes. Patient XYZ is moderately overweight with a BMI of 30 and 10 years ago she was diagnosed with non –insulin depended 10 years ago. She uses oral hypoglycemic medication (glipizide 10 mg twice a day. Allergies: No known allergies or drug allergies. Past Psychiatric Hx: The patient reports she has suffered five episodes of depression. She experienced two major depressive episodes during adolescence and developed post-partum depression and anxiety after the birth of two of her children. Previous psychiatric diagnoses Five episodes of manic depressive episodes. Safety concerns: Since the patient has no suicidal ideation and the patient has no reported history of violence to self or others.-there are no safety concerns worth mentioning. There are no auditory or visual hallucinations. Mental health treatment history discussed: The patient has not reported any hospitalization or prior substance abuse. Past Psych Med Trials: None reported Family Medical Hx: Family Psychiatric Hx: Substance use Suicides Psychiatric diagnoses/hospitalization Developmental diagnoses Social History: XYZ is a married woman with 5 grown children Occupational History: currently None is available Military service History. None reported Education history: None was reported. Developmental History. No developmental history was available (Childhood History) Legal History None reported. Spiritual/Cultural Consideration None reported ROS: Constitutional: No fever but reports an increase in weight. Eye: No issues reported ENT: Denies any issues Cardiac: Negative for cardiac issuers Respiratory: None reported GI: None reported GU No report on hematuria Musculoskeletal: No report on joint pain Skin Negative on skin lesions Neurologic: No seizures Endocrine. None reported Hematologic: Unremarkable. Allergy NKDA Reproductive: No miscarriages in five children(Initial Psychiatric 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…” | |
| Objective | Vital Signs All within normal range exce;pt BMI of 30 Temp: BP: HR: R: O2: Pain: 0 Ht: Wt: BMI:30 BMI Range: LABS: Lab findings Blood sugar levels HgA1c increased with 1% point Tox screen None carried out Alcohol: No substance or alcohol abuse HCG:None carried out Complete Blood count-RBC –count was normal, as was hemoglobin, hematocrit amongst others. Thyroid stimulating hormone test- results had normal values ranging between 0.4 to 4.0 mIU/L Physical Exam: MSE:The patient cooperates and responds to all questions without signs of distress with ful orientation *4. Her personal grooming is congruent to the occasion. All her psychomotor activities are within normal range. XYZ presents with appropriate eye contact and speech is normal. TC:No abnormalities are reported Cognition is fair and appropriate with a near normal concentration span.(Initial Psychiatric SOAP Note Template-Comprehensive nursing paper sample) Judgment appears normal. The patient can articulate her needs and even has a definitive goal to discontinue Paxil because it is causing undesirable side effects. (Initial Psychiatric 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. | |
| Assessment | DSM5 Diagnosis: with ICD-10 codes Dx: – Confirmed depression and anxiety. Because of excessive fears and worries about weight gain. Reports significant tired tiredness and low energy F43 .23 Mixed Anxiety and Depressed Mood(Maina et al, 2016) Dx: – Bi polar affective disorder F31 highly unlikely because there are no extremely high or low mood swings(Bobo, 2017) Dx: – Drug induced Mood disorder highly unlikely because the patient does not abuse alcohol Dx-Obsessive compulsive disorder- Considered unlikely in Patient XYZ case because she does not display fear of contamination or dirt, requiring her things to be orderly or symmetrical or horrific thoughts of losing control and hanging oneself(Pedley et al, 2019). Dx- Organic conditions-Ruled out because depressive symptoms caused by medical illnesses generally have other signs and symptoms that are associated with the primary disease. Since no other disease except non – insulin dependent diabetes is indicated by past history and physical examination, This was ruled out after a complete blood count and thyroid stimulating hormone test helped to rule out anemia and thyroid disease. (Initial Psychiatric SOAP Note Template-Comprehensive nursing paper sample) The patient has the capacity to respond to all psychiatric assessment interview questions and is willing to maintain adherence if the current side effects are managed. Potential risks and benefits were reviewed and the patient is aware about black box warning and the right to decline treatment. (Initial Psychiatric 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 | |
| Plan (Note some items may only be applicable in the inpatient environment) | The treatment plan will address the weight gain, sexual dysfunction and excessive daytime sedation The first step is to use weight management strategies. Instead of having a compulsion to eat to vent unwanted emotions- the patient has now to consider food as a source of nutrition ad not an outlet for depression. The treatment goal is to eliminate sugary drinks by Week one and cut out fried foods the week that follows. Weight issues and depression are closely related. This is because the part of the brain known as the limbic system responsible for emotions also controls appetite. Annythig that disturbs the emotion also disturbs the appetite (Konttinen et al, 2019).. Once the sugary drinks and fried foods are eliminated, the patient is advised to increase her physical activity and limit her sedentary lifestyle like TV watching to les than three hours a day. The next phase is to manage anorgasmia- a sexual dysfunction. (Initial Psychiatric SOAP Note Template-Comprehensive nursing paper sample)To optimize the SD treatment a thorough assessment of sexual functioning before and during therapy isto be carried out using a standardized questionnaire like Arizona Sexual Experiences Scale (Chokka & Hankey , 2018). The drug Sildenafil is prescribed to improve sexual functioning. Another medication is Flibanserin, a non-hormonal oral treatment . Basson & Gilks (2019). Since depression and anxiety disorders significantly impact on sexual interest in women strategies that address the two would also help to address the anorgasmia. Lastly, to address excessive sedation the patient is advised to take a short nap during the day, and get some physical activity like walking. The dose of Paxil can also be lowered and the patient can with the approval of prescribing physician take the medication at bedtime. All these activities are scheduled to take place within 4 weeks. Safety Risk/Plan: Since the patient has not demonstrated any risk of violence to self or others there are no special safety risk measures to consider except adherence to the the treatment plan. (Initial Psychiatric SOAP Note Template-Comprehensive nursing paper sample) Education, Patient education on the need gto adhere to the prescribed drugs and use of non-pharmacological intervention to reinforce the medication. The patient is also advised to adopt a healthy lifestyle, control her dietary intake with the help of a dietician and engage in physical activities. including health promotion, maintenance, and psychosocial needs Referrals: To address her diabetes condition a referral is made to an endocrinologist Follow-up Next follow-up visit is after 2 weeks Half of the time will be spent on coordination of care and psychotherapy (Initial Psychiatric SOAP Note Template-Comprehensive nursing paper sample)sessions. Each visit is projected to last between 50- 59 minutes ____________________________________________ NAME, TITLE Date: Click here to enter a date. Time: X |
References
Basson, R., & Gilks, T. (2018). Women’s sexual dysfunction associated with psychiatric disorders and their treatment. Women’s Health, 14, 1745506518762664(Initial Psychiatric SOAP Note Template-Comprehensive nursing paper sample)
Bobo, W. V. (2017, October). The diagnosis and management of bipolar I and II disorders: clinical practice update. In Mayo Clinic Proceedings (Vol. 92, No. 10, pp. 1532-1551). Elsevier.(Initial Psychiatric SOAP Note Template-Comprehensive nursing paper sample)
Chokka, P. R., & Hankey, J. R. (2018). Assessment and management of sexual dysfunction in the context of depression. Therapeutic advances in psychopharmacology, 8(1), 13-23.(Initial Psychiatric SOAP Note Template-Comprehensive nursing paper sample)
Konttinen, H., Van Strien, T., Männistö, S., Jousilahti, P., & Haukkala, A. (2019). Depression, emotional eating and long-term weight changes: a population-based prospective study. International Journal of Behavioral Nutrition and Physical Activity, 16(1), 1-11.(Initial Psychiatric SOAP Note Template-Comprehensive nursing paper sample)
Maina, G., Mauri, M., & Rossi, A. (2016). Anxiety and depression.(Initial Psychiatric SOAP Note Template-Comprehensive nursing paper sample)
Pedley, R., Bee, P., Wearden, A., & Berry, K. (2019). Illness perceptions in people with obsessive-compulsive disorder; A qualitative study. Plos one, 14(3), e0213495.(Initial Psychiatric SOAP Note Template-Comprehensive nursing paper sample)
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