Psychiatric SOAP Note Template
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. Refer to the Psychiatric SOAP Note PowerPoint for further detail about each of these sections.
Criteria Clinical Notes Subjective Include chief complaint, subjective information from the patient, names and relations of others present in the interview, and basic demographic information of the patient. HPI, Past Medical and Psychiatric History, Social History. Objective This is where the “facts” are located. Include relevant labs, test results, vitals, and Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…” Include MSE, risk assessment here, and psychiatric screening measure results. Assessment Mini mental assessment goes here, normal for patient
ICD-10 code will be a 25 minute visit Diagnosis: ADHD Test performed is ADHD screening
Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes,
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treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment. Plan
-Start Adderall 5 mg PO daily, possible increase of dose to 10 mg depending on patient’s response to the treatment -EKG and basic labs, CBC, BMP to have a baseline level -Bring patient back in 2 weeks to follow up and see if treatment is effective. -Recommend relaxation techniques at night time and/or use Magnesium for anxious mood at night
Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options and complimentary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment.
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