Study Notes NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation
1. Introduction
The SOAP note is a structured documentation method used in clinical practice.
In psychiatric evaluation, it ensures clarity, organization, and completeness of patient information.
SOAP stands for:
Subjective
Objective
Assessment
Plan
In NRNP/PRAC 6665 & 6675 courses, students are trained to use SOAP notes for focused psychiatric evaluations, emphasizing mental health history, mental status examination, and treatment planning.
2. Subjective Data
This section captures patient-reported information. Key components:
Chief Complaint (CC): Patient’s own words describing the main issue.
History of Present Illness (HPI):
Onset, duration, severity, and progression of symptoms.
Associated factors (stressors, triggers).
Past Psychiatric History:
Previous diagnoses, hospitalizations, therapy, medication trials.
Medical History:
Chronic illnesses, surgeries, allergies.
Family Psychiatric History:
Genetic predispositions, family patterns of mental illness.
Social History:
Living situation, employment, education, substance use, legal issues.
Review of Systems (ROS):
Psychiatric focus: mood, sleep, appetite, concentration, suicidal ideation.
Importance: Subjective data provides context for the patient’s lived experience and guides further evaluation.
3. Objective Data
This section includes clinician-observed and measurable findings.
Mental Status Examination (MSE):
Appearance: grooming, hygiene, clothing.
Behavior: eye contact, psychomotor activity.
Speech: rate, volume, coherence.
Mood and Affect: patient’s emotional state vs. observed expression.
Thought Process: logical, tangential, circumstantial.
Thought Content: delusions, obsessions, suicidal/homicidal ideation.
Perception: hallucinations, depersonalization.
Cognition: orientation, memory, attention, abstract thinking.
Insight and Judgment: awareness of illness, decision-making ability.
Physical Exam (if relevant):
Vital signs, neurological findings.
Diagnostic Tests:
Lab work, imaging, screening tools (PHQ‑9, GAD‑7, MMSE).
Importance: Objective data validates subjective complaints and identifies observable psychiatric symptoms.
4. Assessment
This section synthesizes subjective and objective findings into a diagnostic impression.
Primary Diagnosis: Based on DSM‑5 criteria.
Differential Diagnoses: Alternative explanations for symptoms.
Risk Assessment:
Suicide risk, violence risk, substance abuse.
Clinical Impression:
Severity, chronicity, functional impairment.
Importance: Assessment demonstrates clinical reasoning and supports treatment planning.
5. Plan
Outlines next steps for treatment and management.
Pharmacological Interventions:
Medication initiation, dosage adjustments, monitoring.
Psychotherapy:
CBT, DBT, supportive therapy, family therapy.
Referrals:
Specialists, social services, inpatient care.
Patient Education:
Medication adherence, lifestyle changes, coping strategies.
Follow‑Up:
Frequency of visits, monitoring progress.
Safety Planning:
Crisis hotline, emergency contacts, hospitalization if needed.
Importance: The plan ensures continuity of care and patient safety.
6. Documentation Standards
Accuracy: Avoid vague language; use measurable terms.
Confidentiality: HIPAA compliance.
Professional Tone: Objective, nonjudgmental.
Rubric Alignment: In NRNP/PRAC courses, SOAP notes are graded based on completeness, accuracy, and adherence to template.
7. Common Pitfalls
Omitting key psychiatric history.
Incomplete mental status examination.
Lack of differential diagnoses.
Vague treatment plans.
Poor grammar or formatting (important for academic grading and clinical clarity).
8. Example SOAP Note (Abbreviated)
S: Patient reports persistent sadness, poor sleep, and loss of interest for 3 months.
O: Flat affect, slow speech, PHQ‑9 score = 18.
A: Major Depressive Disorder, moderate severity.
P: Initiate SSRI, weekly CBT, follow‑up in 2 weeks, suicide safety plan.
9. Clinical Relevance
SOAP notes are critical for communication among providers, legal documentation, and insurance coding.
In psychiatric practice, they highlight nuances of mental health symptoms that may not be captured in general medical notes.
10. Summary
The Focused SOAP Psychiatric Evaluation is a structured, evidence‑based approach to documenting psychiatric encounters.
Subjective: Patient’s narrative.
Objective: Clinician’s observations.
Assessment: Diagnostic reasoning.
Plan: Treatment and follow‑up. Mastery of this format in NRNP/PRAC 6665 & 6675 ensures clinical competence, academic success, and improved patient outcomes.
📝 Quiz (15 Questions)
Multiple Choice – Select the best answer.
What does SOAP stand for in psychiatric evaluation? a) Symptoms, Observations, Analysis, Plan b) Subjective, Objective, Assessment, Plan c) Signs, Observations, Actions, Prognosis d) Subjective, Objective, Actions, Prognosis
Which section includes the patient’s chief complaint? a) Objective b) Subjective c) Assessment d) Plan
The Mental Status Examination belongs to which SOAP section? a) Subjective b) Objective c) Assessment d) Plan
Which of the following is NOT part of the MSE? a) Mood and Affect b) Thought Content c) Vital Signs d) Insight and Judgment
Family psychiatric history is documented under: a) Objective b) Subjective c) Assessment d) Plan
Which tool is commonly used to assess depression severity? a) MMSE b) PHQ‑9 c) GAD‑7 d) HAM‑A
The assessment section should include: a) Patient’s narrative only b) Diagnostic impression and differential diagnoses c) Medication list d) Vital signs
A suicide risk evaluation is part of: a) Subjective b) Objective c) Assessment d) Plan
Which of the following is a psychotherapy intervention? a) SSRI prescription b) Cognitive Behavioral Therapy c) Blood test d) MRI scan
Patient education is documented under: a) Subjective b) Objective c) Assessment d) Plan
Which section synthesizes subjective and objective findings? a) Subjective b) Objective c) Assessment d) Plan
A vague treatment plan is considered: a) Acceptable in SOAP notes b) A common pitfall c) A diagnostic impression d) A patient narrative
Confidentiality in SOAP notes is guided by: a) DSM‑5 b) HIPAA c) ICD‑10 d) FDA
Which of the following is an example of a chief complaint? a) “I feel anxious all the time.” b) Flat affect observed. c) PHQ‑9 score = 18. d) Initiate SSRI treatment.
Why are SOAP notes important in psychiatric practice? a) They replace therapy sessions. b) They provide structured documentation for communication and care. c) They eliminate the need for diagnosis. d) They are optional in clinical settings.
Answer Key: 1‑b, 2‑b, 3‑b, 4‑c, 5‑b, 6‑b, 7‑b, 8‑c, 9‑b, 10‑d, 11‑c, 12‑b, 13‑b, 14‑a, 15‑b
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