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SOAP notes for Mental Health Examples

This post includes 35 examples of SOAP notes for mental health examples and an outline to get you started. Struggling to do your SOAP Note, thestudycorp.com writers can help. All you need to do is place an order with us.

Clinical SOAP Note Depression (SOAP notes for mental health examples)

CriteriaClinical Notes (SOAP notes for mental health examples)
 
Informed ConsentThe patient gave informed consent on the psychiatric interview process and the subsequent psychiatric/ psychotherapy treatment. This means both verbal and written consent were secured since the patient demonstrated both ability and capacity to respond and appears to fathom the risks, benefits, and promises to review additional consent at any stage of the treatment plan discussions.
Subjective  CC: “I just feel depressed and it’s all my fault”.   HPI: CF is a 51 y/o African American female single lady with a history of depression who presents to the clinic c/o increased anxiety. She admits anxiety has been a chronic problem that has steadily increased in the past few weeks accompanied by lack of sleep, body tension and shaking. She reports just feeling depressed with symptoms such as losing interest in meeting friends, increasingly fatigue and irritable, severity being enough to interfere with activities considered instrumental for daily living. She reports she is currently on medication therapy but feels that the symptoms gradually getting worse despite her taking Lexapro 10 PO once daily. Prior to that, the medication seems to be taking the edge off. She’s positive to many recent life stressors like having a benign tumor on her left breast with subsequent hospitalization and her mother is on her death bed. Six months ago, she lost her older sister and admits she is still in the grieving process. She reports her steady partner was supportive until eight months ago when he decided to move on with the previous relationship from a 30 y/o female workmate. She reports to having consulted a psychiatrist for anxiety/depression in the past. CF denies mood swings, mania, or hypomania behaviors. She denies smoking and claims to be a tee-totaller

Past Medical Hx: Medical history: Patient admits she has hypertension.  Acute illnesses include a loss of a finger after she accidently cut it off while she was chopping a piece of sugarcane at age 33.  Reports a lumpectomy but denies other surgical history

Surgical history: Lumpectomy at age 51 yrs.  

Past Psychiatric Hx: Previous psychiatric diagnoses: diagnosis of, depression, and anxiety. Describes worsening course of illness.

Current Medications: Lexapro 10mg PO once daily           

(Contraceptives): None             

Supplements: Calcium 500mg and Vitamin B6 500mg
Previous medication trials: Unknown.
Allergies: NKDA
Therapy History:   Anxiety: CF confirms significant social anxiety and reported this began in high school.  Reported that she experiences challenge leaving the house and is engulfed with intense fear accompanied by shaking and fast breathing. She has taken Benadryl an OTC medication and found it to be fast acting and convenient though she can’t recall the dosage.
Depression: Patient reports feeling depressed since last year April when a string of misfortunes and tragedies struck her close family members and relatives. The mood swings have increased in intensity in the last two weeks.  She reports inability to sleep in a bed she had shared with her late sister and gets three to four hours of sleep.  Confirms having sought treatment for depression and admits having experienced other episodes prior to this occurrence.
Mental health treatment history discussed: History of outpatient treatment: three-month CBT course for depression Previous psychiatric hospitalizations: Unknown at this time Prior substance abuse treatment: Negative  
history: Client reports no forms of childhood abuse or even as an adult.  
Substance Use: Negative- Patient claims to be a tee–totaller   (SOAP notes for mental health examples)

Past Psych Med Trials: unknown at this time  
Family Medical Hx: Mother at 71 years diagnosed with advanced stage breast cancer, father died at age 63 years due to complications arising from T2DM.  
Family Psychiatric Hx: Noncontributory except for a maternal uncle who committed suicide by taking drug overdose.  
Birth and Development History: Reports no issues with developmental milestones as all were attained with no challenges.         
ROS: Constitutional: Healthy looking AA female, alert, afebrile and in mild acute distress Eyes:  Negative for eye pain, no discharge, and no sight changes.  ENT:  Negative for hearing changes.no running nose, bleeding, no difficulties in swallowing food.     Cardiac:  Denies chest pain, edema or orthopnea.  Respiratory:  Denies shortness of breath, cough or wheeze.  GI:  Negative abdominal pain abdomen is soft, non- tender. Normoactive bowel sounds.  GU:  Negative for excessive thirst and frequent urination.  Musculoskeletal:  Negative for joint pain or swelling.  Skin:  Negative for rash, lesion, abrasions.  Neurologic:  Denies seizures, blackout, numbness or focal weakness.  Endocrine:  Negative for both polyuria and polydipsia.  Hematologic:  Negative for blood clots or easy bleeding or splenectomy  Allergy:  Negative for hives or allergic reaction. Reproductive: LMP 10 days ago Cycle length and frequency 3/28 light bleeding IMB –Absent PCB-Absent Age of Menarche/Menopause- 12 and 48 years respectively Miscarriages G 3 P 2A 1 L 1

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                                HPI
Objective              Vital Signs: BP 151/97, HR 90, Temp 97.5, RR 19, O2 97% Lab tests results CBC:  currently unavailable. TSH- 1.9mU/L BUN levels- 12 mg/dL Serum creatinine levels 0.64mg/dL Physical Exam: None Contributory. MSE: Appearance: Well groomed, dressed for the occasion and appears the stated age Behavior: Composed, focused with intermittent eye contact Attitude: Cooperative, easy to establish a discussion Level of consciousness: Awake, Alert Orientation: A*4 Speech and Language: Soft clear, coherent Mood: context appropriate Affect: Mood congruent, moderately restricted Thought process/form: organized, goal directed, logical Thought content: Depressed, suicidal ideations Suicidality and homicidally: Has history of suicide attempts denies homicidal thoughts Insight and judgement: Insight considered to be good, judgement moderate Attention span: adequate to the needs of an outpatient program, age appropriate Memory: Both recent and remote deemed intact Intellectual functionality: Intellectually capable Relevant Screening Tools GAD-7: Was used to screen for generalized anxiety and her score was 13 –moderate anxiety

Patient Health Questionnaire (PHQ-9) -12 moderate depression Columbia Suicide Severity Rating Scale (C- SSRS): Moderate risk Appearance: Good hygiene, neat appearance, looks stated age 2. Behavior:  Calm, focused, eye contact intermittent 3. Attitude:  Cooperative, friendly, open to discussion 4. Level of Consciousness: Awake and Alert 5. Orientation: Oriented to person, place, and time 6. Speech and Language: Soft, clear, and coherent 7. Mood: Appropriate to context 8. Affect:  Mildly restricted, congruent with mood 9. Thought Process/Form: Organized and goal directed, logical 10. Thought Content: Depression, suicidal thoughts 11. Suicidality and Homicidally: Prior suicidal/homicidal thoughts, denies any suicide attempts 12. Insight and Judgment: Insight deemed good; judgement is fair 13. Attention Span: Appropriate for age and adequate to needs of outpatient program 14. Memory: Recent and remote memory intact 15. Intellectual Functioning:  Intellectually capable Appearance: Good hygiene, neat appearance, looks stated age 2. Behavior:  Calm, focused, eye contact intermittent 3. Attitude:  Cooperative, friendly, open to discussion 4. Level of Consciousness: Awake and Alert 5. Orientation: Oriented to person, place, and time 6. Speech and Language: Soft, clear, and coherent 7. Mood: Appropriate to context 8. Affect:  Mildly restricted, congruent with mood 9. Thought Process/Form: Organized and goal directed, logical 10. Thought Content: Depression, suicidal thoughts 11. Suicidality and Homicidally: Prior suicidal/homicidal thoughts, denies any suicide attempts 12. Insight and Judgment: Insight deemed good; judgement is fair 13. Attention Span: Appropriate for age and adequate to needs of outpatient program 14. Memory: Recent and remote memory intact 15. Intellectual Functioning:  Intellectually capable Appearance: Good hygiene, neat appearance, looks stated age 2. Behavior:  Calm, focused, eye contact intermittent 3. Attitude:  Cooperative, friendly, open to discussion 4. Level of Consciousness: Awake and Alert 5. Orientation: Oriented to person, place, and time 6. Speech and Language: Soft, clear, and coherent 7. Mood: Appropriate to context 8. Affect:  Mildly restricted, congruent with mood 9. Thought Process/Form: Organized and goal directed, logical 10. Thought Content: Depression, suicidal thoughts 11. Suicidality and Homicidally: Prior suicidal/homicidal thoughts, denies any suicide attempts 12. Insight and Judgment: Insight deemed good; judgement is fair 13. Attention Span: Appropriate for age and adequate to needs of outpatient program 14. Memory: Recent and remote memory intact 15. Intellectual Functioning:  Intellectually capable  Appearance: Good hygiene, neat appearance, looks stated age 2. Behavior:  Calm, focused, eye contact intermittent 3. Attitude:  Cooperative, friendly, open to discussion 4. Level of Consciousness: Awake and Alert 5. Orientation: Oriented to person, place, and time 6. Speech and Language: Soft, clear, and coherent 7. Mood: Appropriate to context 8. Affect:  Mildly restricted, congruent with mood 9. Thought Process/Form: Organized and goal directed, logical 10. Thought Content: Depression, suicidal thoughts 11. Suicidality and Homicidally: Prior suicidal/homicidal thoughts, denies any suicide attempts 12. Insight and Judgment: Insight deemed good; judgement is fair 13. Attention Span: Appropriate for age and adequate to needs of outpatient program 14. Memory: Recent and remote memory intact 15. Intellectual Functioning:  Intellectually capable  Appearance: Good hygiene, neat appearance, looks stated age 2. Behavior:  Calm, focused, eye contact intermittent 3. Attitude:  Cooperative, friendly, open to discussion 4. Level of Consciousness: Awake and Alert 5. Orientation: Oriented to person, place, and time 6. Speech and Language: Soft, clear, and coherent 7. Mood: Appropriate to context 8. Affect:  Mildly restricted, congruent with mood 9. Thought Process/Form: Organized and goal directed, logical 10. Thought Content: Depression, suicidal thoughts 11. Suicidality and Homicidally: Prior suicidal/homicidal thoughts, denies any suicide attempts 12. Insight and Judgment: Insight deemed good; judgement is fair 13. Attention Span: Appropriate for age and adequate to needs of outpatient program 14. Memory: Recent and remote memory intact 15. Intellectual Functioning:  Intellectually  

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AssessmentDSM5 Diagnosis: with ICD-10 codes Diagnosis F33.1 Major Depressive DisorderF41.1 Generalized Anxiety DisorderF31.9 Bipolar disorderF40.0 Agoraphobia  

Differential Diagnoses:

F33.1 Major Depressive Disorder Recurrent, Moderate (MDD)-confirmed Bains & Abdijadid (2021) note that individuals who present with sleep disturbances, report a significant loss of interest in activities that used to give them pleasure and are currently guilt ridden for real or imaged causes and feeling worthless are likely candidates for MDD diagnosis. Using the Mnemonic SIG-E-CAPS the MDD diagnosis was confirmed because in addition to sleeplessness, interest loss in earlier pleasurable activities and guilt- complex, the patient reports lack of energy manifesting as fatigue. While her cognition is not significantly affected excessive appetite, and psychomotor agitation through anxiety and being haunted with suicidal thoughts. Most importantly these symptoms have lasted for more than six months increasing in intensity in the last seven weeks. Some potential medications to treat MDD are Selective serotonin reuptake inhibitor: Lexapro, Sertraline and Fluoxetine. Serotonin-norepinephrine reuptake inhibitors with Cymbalta and Effexor can be another substitute if SSRI are to be excluded. SSRI classification of medication would be adequate choice for the patient because of the cost, targets depressions and anxiety, studied efficacy and acceptability for most patients with minimal side effects. The patient will benefit from Lexapro because she has been successful with the medication on the lower dose, maybe increasing the dose will be first intervention before switching to another SSRIs. Lexapro regulates a wide range of human behavioral processes, which includes mood, perception, memory, anger, aggression, fear, stress response, appetite, addiction, and sexuality (Landy et. al., 2022). Considering increasing the dose of the Lexapro will be next step as patient tolerates the medication with no side effect.  
F41.1 Generalized Anxiety Disorder (Confirmed) Mental healthcare providers are reminded that GAD and MDD can co-occur and even have some overlapping symptoms like irritability, insomnia, and restlessness. A patient with GAD constantly worries and has difficulties controlling the worry (Stein et al, 2021). It was confirmed as a co-occurring condition t because the patient in context has mood swings, displays a flat affect with marked appetite changes as evidenced in excessive eating in addition to palpitations and fast breathing amongst other signs and symptoms of GAD. Some potential medications to treat GAD are Selective serotonin reuptake inhibitor: Lexapro, Sertraline and Fluoxetine; Serotonin-norepinephrine reuptake inhibitors with Cymbalta and Effexor can be another substitute if SSRI are to be excluded as mentioned on MDD. The patient will benefit from Lexapro because she has been successful with the medication on the lower dose, maybe increasing the dose will be first intervention before switching to another SSRIs. Considering increasing the dose of the Lexapro will be next step as patient tolerates the medication with no side effect   (SOAP notes for mental health examples)

F31.10 Bipolar Disorder unspecified –(Refuted) CF symptoms as reported are considered unlikely because she admits to not having marked impairment and has never been admitted to the hospital for psychiatric reasons. She denies exhibiting mood swings, mania, or hypomania behavior. Patient with bipolar disorder will most likely experience a full manic episode necessitating admission to a psychiatric institution, unlike their bipolar II who experience a less severe hypomanic episode with depression.

F40.0 Agoraphobia – (Refuted) This diagnosis does not pertain to CF. Patient reports anxious behavior but did not report around others, especially in crowds at school or feeling trapped.

Treatment goals:
(F33.1) Major Depressive Disorder Recurrent, Moderate – Reduction of depressive behaviors, able to enjoy things that she normally enjoys without affecting her daily lives (Reduce PHQ 9 score). Increasing the dose of Lexapro will help restore healthy balance of serotonin in the brain and improve her quality of life.

(F41.1) Generalized Anxiety Disorder – Improved coping with anxiety and anxiety symptoms (Reduce GAD 7 score). Increasing the dose of Lexapro will help restore healthy balance of serotonin in the brain and improve her quality of life.In case of a missed dose, CF should take it as soon as possible but if the next dose is almost due, CF should skip the missed dose and go back to her regular dosing schedule. CF should not take a double dose.Plan to incorporate teaching/ patient education on how to overcome some of the life challenges through adjunct psycho education for the patient and key family caregivers. CF should be discouraged on the use of OTC medications.CF should also be encouraged to engage in physical activity. Patient will benefit from cognitive behavioral therapy (CBT) which is the most evidence-based psychological interventions for the treatment of depression and anxiety disorders.   (SOAP notes for mental health examples)

Informed Consent Ability: Patient has ability/capacity appears to respond to psychiatric pharmacological and psychotherapy interventions and appears to understand the need for medications/psychotherapy and ready and willing to adhere to the recommended treatment and care plan.

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Informed Consent Ability
PlanPharmacological Interventions   The escitalopram dosage should be increased to 20mg /day to determine the medication’s maximum effectiveness. (Jiang et al, 2016). According to this researcher, the efficacy of Lexapro medication in treating MDD comorbid with generalized anxiety disorder has been determined in short term studies. The drug works by increasing intrasynaptic levels of neurotransmitters serotonin. It does this action by blocking the reuptake of the neurotransmitter into the presynaptic neuron. Will obtain CBC with diff, fasting lipids and HbgA1C. (SOAP notes for mental health examples)

Nonpharmacological interventions Education First education to CJ was to be aware about the importance of adhering with her medication and CBT times.The patient should be made aware of Escitalopram 20mg side effects of headache, nausea, dry mouth, and constipation. Other side effects associated are weight gain, flatulence, menstrual disorder, and decreased libido. CJ was educated to avoid any use of alcohol, nicotine, or drugs, including medications not prescribed for her.Patient was informed to communicate with other people and talk with people she trusts about how she’s feeling.Attend to all your psychiatrist and therapists’ appointmentsEducate patient on relaxation techniques to lower stress.Educate CJ to do things that she enjoys such as (gardening, walking in nature, going to a movie). Always Reward self for every success.  

Referral The patient is to be referred to a Psychotherapist for CBT.The patient will be referred to the Primary care Physician for follow up regarding the mild BP elevation.  

Follow up Return for follow up in 4-6 weeks, or earlier if the symptoms get worse despite the increased dosage of Lexapro to 20mg.

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Clinical SOAP Note Schizophrenia (SOAP notes for mental health example)

CriteriaClinical Notes (SOAP notes for mental health examples)
 
Informed ConsentInformed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion)
SubjectiveChief Complaint: “The counselor brought me in for my medicine.”   History of Present Illness: A 53-year-old African American male with a diagnosis of schizophrenia, alcohol use disorder, cannabis use disorder, and cocaine use disorder is brought into the clinic by a counselor. Patient has been established at the clinic for the last two years but has been missing his appointments for last three months due to being homeless and lack of transportation. The counselor happened to see him on the street and decided to bring him in for an appointment. Patient reports being non-compliant with his monthly Invega Sustenna shot for the last three months. Patient reports that the medications have been working well with him, however, the Invega Sustenna has been making him grow “man boobs”, so he would like to try another medication. He also reports of auditory and visual hallucinations that started about two months ago but has been gradually getting worse. He states that nothing makes it better, but cannabis and cocaine makes it worse. Patient also reports he has been drinking excessively since he lost his home would like to quit drinking. He reports drinking 1-3 pints of whisky per day. He states that his drinking consumption depended on how much money he made from pan-handling that day. He reports that stress from losing his home causes him to drink alcohol and consume cannabis and cocaine. Patient reports that cannabis and cocaine consumption also had depended on how much money he had.  
Medical History: None  
Past Psychiatric History: Schizoaffective disorder, alcohol use disorder, cannabis use disorder, cocaine use disorder  
Current Medications: Invega Sustenna 156mg IM every 4 weeks  
Previous Psych Med Trials: Risperdal, Invega, and Abilify.  
Allergies: Does not report any drug, food, and environmental allergies.  
Therapy History: Was attending psychotherapy sessions with a licensed counselor weekly the past two years but missed therapy sessions the last 3 months.  
Trauma History: Denies history of physical and sexual trauma. Reports being neglected by family due to his mental illness.  
Substance Use: Patient reports drinking 1-3 pints of whiskey almost daily. Reports smoking 1 pack cigarettes daily, smoking marijuana about 3 times a week, and snorting cocaine about two to three times a month.  
Social History: Single, living homeless on the street. Unemployed. Patient was living with his brother, however, brother kicked him out of the house due to drug use about three months ago.  
Family History: Unknown.  
Family Psychiatric History: Unknown.  
Birth and Developmental History: Reports he had hit all developmental milestones on schedule.  
Review of systems: General: Denies fever, chills, appetite changes, weight loss, and weight gain. 
Head, eyes, ears, nose, and throat: Denies visual changes, hearing changes, and trouble swallowing. 
Integumentary: Denies any skin rashes, lesions, wounds, and changes. 
Cardiovascular: Denies chest pain. 
Lungs: Denies breathing difficulties. 
Gastrointestinal: Denies nausea, vomiting, constipation, diarrhea, and abdominal pain. Has 1-2 bowel movements per day.
Genitourinary: Denies urinary frequency and difficulty in urination. 
Peripheral vascular: Denies peripheral edema of all extremities. 
Musculoskeletal: Denies any joint or muscle pain
Neurological: Denies headaches, dizziness, confusion, or weakness.
Endocrine: Denies endocrine issues. 
Psychologic: Reports having auditory and visual hallucinations.
(SOAP notes for mental health examples)
Objective                Vitals: Height: 5’10”    Weight: 170    BMI: 24.4    BP: 128/24    HR: 78    RR: 16    T: 98.6F   Labs: Unavailable at this time.   Mental Status Exam: Observation: Appearance: Clothing soiled, but appropriately dressed for age and seasonSpeech: Spontaneous, appropriate rate, appropriate tone, and low volume without pressured speech, with some problems expressing selfEye contact: IntermittentMotor Activity: NormalAffect: Full, even, and congruent with mood Mood: “Good” Cognition: Orientation: Alert, oriented to person, place, time, and situationMemory: IntactAttention/Concentration: Limited Perception: Reports auditory and visual hallucinations Thought Content: Suicidality: NoneHomicidality: NoneDelusions: None Thought Process: Disorganized with flight of ideas Behavior: Cooperative and conversant, appears without acute distress Insight: Poor Judgment: Poor   Schizophrenia Assessment Tool: PANSS positive scale score: 24 PANSS negative scale score: 12 PANSS general psychopathology scale score: 33 Total PANSS score= 69   Alcohol Use Assessment Tool: AUDIT score= 36   Cannabis and Cocaine Use Assessment Tool: DAST-10 score= 8   Physical Exam: Not applicable

AssessmentDiagnosis: (F20.9) Schizophrenia(F10.29) Alcohol use disorder (F14.988) Cocaine use disorder (F12.90) Cannabis use disorder  

Differential Diagnosis: (F10.259) Alcohol-induced psychotic disorder(F14.259) Cocaine-induced psychotic disorder(F12.259) Cannabis-induced psychotic disorder   This was a follow up appointment from being noncompliant with follow up appointments and treatment for the last three months. The patient appeared to decline since his last appointment three months ago.   (SOAP notes for mental health examples)

Assessment of Current Psychiatric and Medical Condition(s) or Drug Therapy-related problems: It appears that the patient is experiencing psychosis related to schizophrenia as seen by the PANSS score of 69. Additionally, AVH is worsened by substance use disorders. He also has alcohol use disorder as evidenced by his AUDIT score of 36. And has cannabis use disorder and cocaine use disorder as evidenced by his DASH-10 score of 8. He was taking Invega Sustenna but was experiencing gynecomastia and was asking for another medication that would help treat schizophrenia without having gynecomastia as a side effect.   Some potential medications to treat schizophrenia are antipsychotics such as Abilify Maintena, Caplyta and Vraylar. Abilify Maintena would be a great choice for this patient since he is homeless and noncompliant. The patient would not have to worry about carrying around medications, medications getting lost/stolen, or taking them. Would be convenient for him to stay compliant since he will be given the shot every four weeks when he comes in for his follow up appointments. Caplyta is also a great choice since it is a fast-acting antipsychotic, which will show improvement in his symptoms in one week. However, since this is a pill that has to be taken every day, the patient would have trouble being compliant, which would make the medication ineffective since it has a short half-life. I also think Vraylar is a good choice of medication since it hits the D3 receptors which is known to help those with addiction issues. It also has a long half-life, so if he misses a day, he would not be affected. However, again, this is a pill, so it would be hard for him to stay compliant with taking an oral medication. Also, all these medications do not increase prolactin levels significantly which causes gynecomastia, which he is concerned about.   Some potential mediations to treat alcohol use disorder is naltrexone and Vivitrol. Since the patient is homeless and noncompliant with taking oral medications daily, I don’t think naltrexone is a good choice. I think Vivitrol is a great choice for this patient since it is a shot to be given monthly, which he can get every four weeks when he comes in for his follow up appointment.   Currently there are no medications to help with cocaine use disorder and cannabis use disorder.   I believe that this patient can significantly benefit from attending cognitive behavioral therapy (CBT) to help with schizophrenia, in addition to his multiple substance use disorders. CBT is known to help with schizophrenia and substance use disorders.   (SOAP notes for mental health examples_

Treatment Goals: (F20.9) Schizophrenia- to reduce/stop auditory and visual hallucinations, so it does not affect patient from performing daily duties (decrease in PANSS score)(F10.29) Alcohol use disorder- to reduce alcohol consumption to prevent the exacerbation of AVH (decrease in AUDIT score)(F14.988) Cocaine use disorder- to reduce/stop cocaine consumption to prevent the exacerbation of AVH (decrease in DASH-10 score)(F12.90) Cannabis use disorder- to reduce/stop cannabis consumption to prevent the exacerbation of AVH (decrease in DASH-10 score)(F10.259) Alcohol-induced psychotic disorder- to reduce alcohol consumption to prevent the exacerbation of AVH (decrease in PANSS and AUDIT score)(F14.259) Cocaine-induced psychotic disorder- to reduce/stop cocaine consumption to prevent the exacerbation of AVH (decrease in PANSS and DASH-10 score)(F12.259) Cannabis-induced psychotic disorder- to reduce/stop cannabis consumption to prevent the exacerbation of AVH (decrease in PANSS and DASH-10 score) The patient appears to understand the need for medication and psychotherapy. The patient is willing to adhere to the treatment plan. Reviewed potential risks & benefits, Black Box warnings, and alternatives, including declining treatment. (SOAP notes for mental health examples)

PlanTherapeutics: Stop Invega Sustenna IM every 4 weeks due to gynecomastia. Start Abilify Maintena 800mg IM one time today and Abilify 20mg PO one time today, then Abilify Maintena 400mg IM every 4 weeks for schizophrenia. My preceptor chose to initiate Abilify Maintena 800mg IM with Abilify 20mg PO on day 1, then Abilify 400mg IM every 4 weeks versus Abilify Maintena 400mg IM on day 1 with Abilify 20mg for 14 days because patient stated that he would not be compliant with taking oral medication. Patient is also known to tolerate Abilify well in the past. Start Vivitrol 380mg IM every 4 weeks for alcohol use disorder. Order fasting lipids, HbgA1C, CBC with diff, and fasting plasma glucose to get baseline since atypical antipsychotics can cause multiple metabolic side effects and leukopenia/neutropenia. Order liver panel since Vivitrol is metabolized in the liver and since the patient has a history of drinking daily.   Educational: Educate the patient on the importance of being compliant with medication and psychotherapy. Educate the patient on the common and dangerous side effects of Abilify Maintena and Vivitrol. Some side effects of Abilify Maintena include dizziness, insomnia, akathisia, nausea, and vomiting. Some side effects of Vivitrol include nausea, vomiting, dizziness, insomnia, and headache. Educate the importance of sleep hygiene, meditation, and yoga for overall mental health. Educate the importance of physical activity to help prevent the metabolic side effects from an atypical antipsychotic. Educate patient on the importance of psychotherapy, specifically cognitive-behavioral therapy, to help with schizophrenia and substance use disorders. Patient was educated on the negative effects of alcohol, cannabis, and cocaine. The benefits of joining a substance abuse rehabilitation program were discussed. Also discussed patient to see primary care provider to get a full body health assessment and labs.   Consultation/Collaboration: Continue psychotherapy with the psychologist or licensed counselor every week—cognitive behavioral therapy for schizophrenia and multiple substance use disorders. Consult with a social worker to help patient find housing and clothes. Consult substance abuse rehabilitation program for multiple substance use disorders. Consult primary care provider to perform annual preventative health assessment and labs.   Follow up: Follow up in two weeks- will initially follow up every two weeks the first two months, then every four weeks to see patient’s progress. Will continue to monitor PANSS, AUDIT, and DASH-10 scores. Will also monitor labs every six months and report any abnormal labs to primary care provider. (SOAP notes for mental health examples)



Outline of a Mental Health SOAP note

CriteriaClinical Notes– SOAP notes for mental health examples
 
Informed ConsentInformed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion)
SubjectiveVerify Patient           Name: AA           DOB: 5/15/02   Minor: N/A Accompanied by: none   Demographic: Patient is a 20-year-old Caucasian male brought to facility by family member from home in Eastern United States.  Patient presents for treatment related to substance abuse and is voluntarily admitted.  Patient owns own home and works full time.  Was living with girlfriend until three weeks ago.  Graduated high school and attended trade school for one year for welding. Has no children and is unmarried.  Reports having a supportive family consisting of mother and several cousins. Denies having a social circle or supports.   Gender Identifier Note: Male   CC: “I’ll die out there without help”.   HPI: : Patient reports beginning substance abuse in the last three weeks following the discovery of his longtime live-in girlfriend’s infidelity with one of his male family members.  Indicates he “went off the rails” and began taking non-prescribed opiates and benzodiazepines.  Indicates he has been taking around seven tablets of Norco 5/325 daily and three Xanax “bars” (2 mg tablets) per day for approximately three weeks.  Reports last use of Norco and Xanax 36 hours ago. Patient denies use of opiates and benzodiazepines in the past.  Patient indicated he has smoked marijuana regularly since the age of 17 and takes several “hits” daily.  Reports he smokes a full joint, around one gram, every week.  Patient reported he uses marijuana to reduce anxiety.  Reports last use of marijuana 12 hours ago. Patient reports he has been unable to stop his use on his own; is failing to meet obligations with work and at home; is engaging in dangerous behavior, such as driving under the influence; is not attending to activities of daily living; spends significant time attempting to obtain or recover from use; reports having cravings; and describes tolerance as manifested by needing to take substances more frequently or in greater amounts to obtain desired effect and experiencing withdrawal symptoms when unable to obtain substances.  Denies other substance use. Patient indicated he feels depressed, reporting intermittent tearful episodes, bursts of anger, feelings of guilt, shame, and worthlessness and has attempted suicide three times in a three-week span.  Reported he has access to numerous firearms including rifles and shotguns used for hunting and pistols used for personal protection and sport.  Indicated his first attempt occurred within days of his discovery and he put a pistol to his head.  He reports his girlfriend talked him out of shooting himself, but he reports discharging the weapon twice in the room, shooting the bed and dresser mirror.  His second attempt was via overdose the following week and reports having taken around 60 quantity of buspirone of unknown dosage. He indicated this made him drowsy and unable to move, and he reports not seeking medical assistance when regaining his faculties.  The third attempt involved homicidal ideation in which the patient waited in the woods with a shotgun for the accused male family member to return home at which point he planned to commit a murder-suicide with that weapon.  Patient stated, “the only reason I’m alive is because he didn’t come home”.  Patient continues to report suicidal ideation with intent and plan to shoot himself, as well as a plan to murder the male family member first.      Pertinent history in record and from patient: yes   During assessment: Patient describes their mood as poor and indicated it has gotten worse in three weeks.   Patient self-esteem appears poor,   reported feelings of excessive guilt, no reported anhedonia, does not report sleep disturbance,  does report decrease in appetite,  does not report libido disturbances, does not report change in energy, no reported changes in concentration or memory.   Patient does report increased activity, denies agitation, denies risk-taking behaviors, denies pressured speech, or euphoria.  Patient does not report excessive fears, worries or panic attacks. Patient does not report hallucinations, delusions, obsessions or compulsions.  Patient’s activity level, attention and concentration were observed to be within normal limits.  Patient does not report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a characterological nature.  (SOAP notes for mental health examples)

SI/ HI/ AV: Patient currently reports suicidal ideation, denies SIBx, reports homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors.  

Allergies: NKDFA. (medication & food)  
Past Medical Hx: Medical history: Patient reports he has no chronic medical conditions.  Acute illnesses have included a broken right femur related to a sports injury at 15 years old and several incidences of strep throat.  Reports received a tonsillectomy at age seven. Denies other surgical history.  Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C. Surgical history tonsillectomy age 7 .
Past Psychiatric Hx: Previous psychiatric diagnoses: diagnosis of PTSD, depression, and anxiety. Describes deteriorating course of illness.
Previous medication trials: unknown at this time. PTSD: Patient reported extensive emotional and physical abuse by his father “for as long as I can remember”.  Indicated he was left with him periodically by his mother and, while intoxicated, the father would strangle him to the point of losing consciousness.  He reports also witnessing his father beat several women “into a bloody pulp”.  Reports he startles easily at the sound and sight of men and has become physically aggressive at work when a male coworker startled him. He reports punching the man in the face and breaking his jaw. 
Anxiety: Patient reports significant social anxiety and stated this began in middle school.  Reported that he struggles with leaving the house, experiences panic attacks which he describes as intense shaking and rapid breathing and has thoughts that “won’t shut off”.  Patient reports he has taken paroxetine and buspirone in the past but cannot recall the dosage of either medication.  Indicated was not taking buspirone regularly and believes prescription was outdated.  Cannot recall when he last took paroxetine and believes it was prescribed when he was 18 years old.  Indicated he trialed it for around six months and found it to be ineffective.  Reported he refused to trial additional medications. 
Depression: Patient reports feeling depressed for three weeks.  Indicated he has not been able to sleep in their formerly shared bed and has been attempting to sleep in his truck.  Reports sleeping one to two hours per night.  Indicated he no longer has an appetite and reports feeling nauseous when eating.  Indicated he no longer finds joy in any activities and lacks the motivation to go to work, reporting feeling “my rage is the only thing keeping me going”.  Denies having sought treatment for depression or having experienced other episodes prior to this occurrence.     SOAP notes for mental health examples
Safety concerns: History of Violence to Self:  three previous suicide attempts, see HPI for further details History of Violence to Others: attempted, see HPI for further details     Auditory Hallucinations: denies Visual Hallucinations: denies
Mental health treatment history discussed: History of outpatient treatment: unknown at this time Previous psychiatric hospitalizations: Unknown at this time Prior substance abuse treatment:      
Trauma history: Client reports abuse from father, see above for further details   Substance Use: Client denies use or dependence on nicotine/tobacco products. Client reports opioid and benzodiazepine and cannabis use, see above for further details   Current Medications: None at this time            (Contraceptives): N/A              Supplements: N/A   Past Psych Med Trials: unknown at this time   Family Medical Hx: Unknown   Family Psychiatric Hx: Father:unknown diagnosis but was abusive   Social History: Occupational History: currently employed full-time as a welder       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: no reported/known legal issues, no reported/known conservator or guardian. Spiritual/Cultural Considerations: none reported.            ROS: Constitutional:  No report of fever or weight loss.  Eyes:  No report of acute vision changes or eye pain.  ENT:  No report of hearing changes. Patient indicated he has painful swallowing since the age of 9 following being strangled by his father.     Cardiac:  No report of chest pain, edema or orthopnea.  Respiratory:  Denies dyspnea, cough or wheeze.  GI:  No report of abdominal pain.  GU:  No report of dysuria or hematuria.  Musculoskeletal:  No report of joint pain or swelling.  Skin:  No report of rash, lesion, abrasions.  Neurologic:  No report of seizures, blackout, numbness or focal weakness.  Endocrine:  No report of polyuria or polydipsia.  Hematologic:  No report of blood clots or easy bleeding.  Allergy:  No report of hives or allergic reaction. Reproductive: No report of significant issues. (females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…)  SOAP notes for mental health examples
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: Stable Temp:             Urine drug screen positive for opiates, benzodiazepines, and THC. Breathalyzer – 0.0 COWS – 16 Most recent vital signs: BP 162/98, HR 92, Temp 97.3, RR 18, O2 98%   No blood work currently available. GAD-7: 13 PHQ-9: 25 points       Physical Exam: MSE: Patient appears disheveled and unkept.  Hair is unclean and tangled.  Patient is diaphoretic with a visible tremor.  Patient noted to yawn several times in short succession.  Patient noted to have watery eyes and runny nose.  Skin is intact without bruises, abrasions, or open areas.  Patient speech is tangential at times but able to be redirected. Limited insight and impaired judgement. Patient is cooperative. Patient mood is depressed and affect congruent.  Patient noted to be picking at hangnails on several fingers throughout examination. Patient avoidant of eye contact. Patient noted to have motor retardation. Patient is oriented to person, place and time. Patient able to recall last five presidents. Patient able to learn and correctly recall three items.  Patient able to recount a numeric sequence forward and backward without error. Exhibits intact immediate recall, short and long-term memory, concentration, attention, impulse control, and introspection.   The patient is able to articulate needs, is motivated for compliance and adherence to medication regimen. Patient is willing and able to participate with treatment, disposition, and discharge planning (SOAP notes for mental health examples)
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.
AssessmentDSM5 Diagnosis: with ICD-10 codes   Patient is suffering from opiate and benzodiazepine withdrawal and exhibits signs of major depression with suicidal and homicidal ideation. Patient meets DSM-V criteria for:   opiate use disorder, severe (F11.20); Patient reports the past three weeks daily use of Norco 5/325 with 7 tablets per day. Last use was 36 hours ago. Patient reports he has been unable to stop his use on his own; is failing to meet obligations with work and at home; is engaging in dangerous behavior, such as driving under the influence; is not attending to activities of daily living; spends significant time attempting to obtain or recover from use; reports having cravings; and describes tolerance as manifested by needing to take substances more frequently or in greater amounts to obtain desired effect and experiencing withdrawal symptoms when unable to obtain substances. Per objective observation patient has physical symptoms of withdrawal with diaphoresis, watery eyes and runny nose, and tremors. There is motor retardation as well. According to guidelines from the American Society of Addiction Medicine (ASAM, 2020) pharmacology treatment options include methadone (mu agonist) for withdrawal management and treatment, buprenorphrine (partial mu-agonist) for withdrawal management and treatment, naltrexone (antagonist) relapse prevention, Naloxone (antagonist) for reversing an overdose, lofexidine (alpha-2 adrenergic agonist) for withdrawal management, and clonidine (alpha-2 adrenergic agonist) for withdrawal management. Cognitive Behavior Therapy (CBT) has strong evidence of being beneficial for those with substance use disorders as well as Motivational Interviewing (Carroll & Kiluk, 2017; Ingersoll, 2022).   anxiolytic use disorder, severe (F13.20); Patient reports three Xanax “bars” (2mg tablets) daily for three weeks with last use 36 hours ago. Patient reports he has been unable to stop his use on his own; is failing to meet obligations with work and at home; is engaging in dangerous behavior, such as driving under the influence; is not attending to activities of daily living; spends significant time attempting to obtain or recover from use; reports having cravings; and describes tolerance as manifested by needing to take substances more frequently or in greater amounts to obtain desired effect and experiencing withdrawal symptoms when unable to obtain substances. Evidence of withdrawals from observation of diaphoresis, tremors. Treatment of withdrawal typically consists of slowly reducing dosage, carbamazepine (Tegretol) or Phenobarbital taper may be beneficial as well (Sadock et al., 2015). Close monitoring in the hospital may be warranted due to increased risk of seizures (Sadock et al., 2015). Cognitive Behavior Therapy (CBT) has strong evidence of being beneficial for those with substance use disorders as well as Motivational Interviewing (Carroll & Kiluk, 2017; Ingersoll, 2022).   cannabis use disorder, severe (F12.20); Patient indicated he has smoked marijuana regularly since the age of 17 and takes several “hits” daily.  Reports he smokes a full joint, around one gram, every week.  Patient reported he uses marijuana to reduce anxiety.  Reports last use of marijuana 12 hours ago. Patient reports he has been unable to stop his use on his own; is failing to meet obligations with work and at home; is engaging in dangerous behavior, such as driving under the influence; is not attending to activities of daily living; spends significant time attempting to obtain or recover from use; reports having cravings; and describes tolerance as manifested by needing to take substances more frequently or in greater amounts to obtain desired effect and experiencing withdrawal symptoms when unable to obtain substances. Treatment of cannabis abuse is similar to other substances. Support from family and treatment teams are encouraged (Sadock et al., 2015). Cognitive Behavior Therapy (CBT) has strong evidence of being beneficial for those with substance use disorders as well as Motivational Interviewing (Carroll & Kiluk, 2017; Ingersoll, 2022).   Major Depressive Disorder, severe, single episode (F32.2); Patient reports symptoms of depression for greater than 2 weeks, anhedonia, sleep difficulties, amotivation, decreased hunger. He presents with a disheveled look, sad affect and reported mood. Treatment include medication management, typically starting with an SSRI such as sertraline (Zoloft) or citalopram (Celexa). SNRI’s are indicated as well such as venlafaxine (Effexor) or duloxetine (Cymbalta). Additional medication management therapies may be indicated as assessment continues such as addition of low dose aripiprazole (abilify) (Sadock et al., 2015). Psychosocial treatments include CBT, interpersonal therapy, and family therapy (Sadock et al., 2015).   Anxiety, unspecified (F41.9).  Patient has a history of social anxiety and panic attacks with symptoms of shaking, rapid breathing, and thoughts that “don’t’ shut off”. He was observed to be picking at his nails throughout the appointment. Some treatment options would include start of an SSRI such as paroxetine (Paxil) or the above mentioned medications (Sadock et al., 2015). Buspirone (Buspar) is another option to consider along with therapies such as CBT (Sadock et al., 2015).   Differential Diagnoses: Agoraphobia – related to patient’s report of being anxious around others, especially in crowds at school, feeling trapped Cyclothymia – given the patient’s recounting of past trauma and limited description of happiness and functioning independently, this may be an appropriate diagnosis.           Patient has the ability/capacity appears to respond to psychiatric medications/psychotherapy and appears to understand the need for medications/psychotherapy and is willing to maintain adherent. Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment. Assessed for risk factors for suicide: History of impulsivity Suicide Protective Factors: Actively making future plans, verbalizes hope for the future, has responsibility to family and significant other, has belief that suicide is immoral (religious, particularly Christian), hopeful that current treatment is effective, taking steps to engage in treatment. There is no evidence of acute risk for harm to self or others.
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)  Inpatient:   Safety Risk/Plan:  Patient is found to be unstable and has questionable control of behavior. Patient likely poses a high risk to self and a high  risk to others at this time.  Patient denies abnormal perceptions and does not appear to be responding to internal stimuli.   Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic: Referral will be made to case management for a duty to warn per facility protocol. Patient to create safety contract with therapist. Patient to be placed on 72-hour hold. COWS assessment every four hours for five days r/t detox. Medications: Fluoxetine 20 mg PO daily for depression Olanzapine 10 mg PO QHS for depression Buspirone 10 mg PO TID for anxiety Phenobarbital taper for benzodiazepine withdrawal as follows: 60 mg PO x 1 day, 30 mg PO BID x 2 days, 15 mg PO BID x 3 days Subutex titration for opiate withdrawal as follows: 2 mg SL every two hours not to exceed 8 mg Subutex taper for opiate withdrawal as follows: 8 mg SL BID to begin x 2 days, 6 mg SL BID x 1 day, 4 mg SL x 1 day, 2 mg SL x 2 days Robaxin 1500 mg PO every 8 hours PRN for muscle pain. Bentyl 20 mg PO every 6 hours PRN for abdominal cramping Colace 100 mg PO BID PRN for constipation Ibuprofen 600 mg PO every 6 hours PRN for pain Multivitamin 1 tablet PO daily for nutritional supplement Ondansetron 4 mg PO every 6 hours PRN for nausea   Education, including health promotion, maintenance, and psychosocial needs Patient will be educated about medication regimen including indications and side effects and adverse reactions. Examples include metabolic effects of antipsychotic use, including weight gain, glucose resistance, and elevated triglycerides.  Patient will also be educated about risk for gastrointestinal upset, sexual dysfunction, activation, and worsening suicidal ideation with initiation of antidepressant.  Patient will be educated about potential for dizziness and headache with use of buspirone.  Patient will be educated about timeframes for therapeutic effect, such as 1-2 weeks for olanzapine and 4-6 weeks for fluoxetine. Educated regarding phenobarbital is being used to help through withdrawals of benzodiazepines and will not be continued upon it’s tapered discontinuation. Subutex education provided regarding use for help with withdrawals. Continuation of this medication to be determined, notable side effects may include headache, constipation, nausea, orthostatic hypotension (Stahl, 2017). Safety planning Labs: CBC CMP HIV – rule out Hep Panel – rule out Fasting glucose – related to antipsychotic initiation Lipid levels – related to antipsychotic initiation   Referrals: Patient will be referred to therapy for Cognitive Behavioral Therapy for MDD and substance abuse. Encouraged participation in Narcotics anonymous and provided list of meeting places in the area. Interdisciplinary team will be notified of trauma history and need to announce self. Males suggested to remain outside of patient’s room.    Follow-up TBD upon closer to discharge     ☒ > 50% time spent counseling/coordination of care.   Time spent in Psychotherapy  15 minutes   Visit lasted 55 minutes   Billing Codes for visit:   99204 XX     ____________________________________________            Date: 2/8/2022    Time: 1300                         



Soap notes for mental health examples
SOAP notes for mental health examples

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