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March 18, 2024

Compose a SOAP note: Pt. is a 54 yo AAM who presents for f/u medication Management.CC’ I have forms for mental

Compose a SOAP note: Pt. is a 54 yo AAM who presents for f/u medication Management.CC’ I have forms for mental health clearance for a new job”. Patient reports he got a job as a floor tech at mercy hospital.He is requesting his mental health clearance paperwork o be filled. He reports he is coming down on his methadone dose and currently he is on 85 mg QD. He reports he stopped taking buspirone as he does not have anxiety anymore. He reports he does not want any other medications and want to remain on seroquel only. Pt. reports improvement in mood, sleep, appetite, and energy level is adequate. All psychotic symptoms are denied. Discussed with patient the importance of appropriate diet, exercises and rest for mental well-being, appointment, and medication compliance. Patient verbalizes understanding. Support and psycho-education provided.

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