Nursing Mini SOAP for a Patient with Bipolar 1 Disorder

Submit 1 Mini-SOAP note on a patient that you saw in clinic this week.

Demographic Data

Patient initial (one initial only), age, and gender must be Health Insurance Portability and Accountability (HIPPA) compliant.
Subjective

Chief Complaint (CC)
History of Present Illness (HPI)?(symptoms) in paragraph format
Past Medical History (PMH):?Current problem-focused and document pertinent information only.
Current Medications:
Medication Allergies:
Social History:?For current problem-focused and document only pertinent information only.
Family History: For current problem-focused and document only pertinent information only.
Review of Systems (ROS) as appropriate:
Objective

Vital signs
Mental Status Exam
Physical findings listed by body systems, not paragraph form.
Patient Health Questionnaires, Screenings, and the results (PHQ-9, GAD 7, suicidal)
Assessment (Diagnosis/ICD10 Code)

Include all diagnoses that apply to this visit.
Include one differential diagnosis.
Plan

Dx?Plan (lab, x-ray)
Tx?Plan: (meds)
Pt. Education, including specific medication teaching points.? ?
Safety Plan? ? ? ?
Referral/Follow-up

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