Patient is a 14 year old male patient who presents with mother for follow-up on depression and ADHD- predominately inattentive type. GR is a 14 year old ma
psych soap note, template and rubric attached.
template attached
Patient name, GR- will fill in remaining name and vitals at end, other stuff will need to develop
HPI: Patient is a 14 year old male patient who presents with mother for follow-up on depression and ADHD- predominately inattentive type. GR is a 14 year old male who presents with his mother for a follow up visit for the management of depression, social anxiety, and binge eating disorder. He takes Vraylar and Venlafaxine ER 150mg. During last visit, we started Vyvanse 20mg due to
poor focus, inattentiveness, and to assist in the binge eating disorder (BED). He reports feeling some improvement. He feels more energy and is not sleeping all day like he used to. He also relates to decreased appetite and denies episodes of binge eating.Gavin still reports sleeping 12 hours at night. He does not take as many naps as he used to. Patient does online school from home. He relates to improved motivation. Gavin reports moderate depressive and anxiety symptoms. PHQ-9 score is 12. GAD-7 score is 14. His mother reports noticing improved mood. He has been going out more and willing to dine at restaurants. We'll continue Venlafaxine ER 150mg daily. Increase to Vyvanse 30mg daily in the morning. Follow up in three weeks.
Chief Complaint, patient "I am feeling more motivated and interested in leaving the house." Mother, states "I see some improvement and he is socializing more with the family at home."
Medications are: Lisdexamfetamine (Vyvanse) 30 mg capsule, take one tablet every morning, Venlafaxine ER 150 mg capsule ER, take one capsule in the morning, every day
Primary Diagnosis, Depression, moderate, recurrent. ADHD-predominately inattentive type, and Binge Eating disorder (BED). Plus in ICD 10 codes
Differentials: Anxiety, Social anxiety, thyroid abnormality, anemia- iron versus folate/ b12 (micro versus macrocytic anemia)
Follow-up in 3 weeks
Continue current prescriptions x 30 days
Will need at least three references, APA- in past five years- in text citations for differentials and main diagnosis
Psychiatric SOAP Note Rubric
|
Criteria |
Ratings |
Points |
|||
|
Chief Complaint (Reason for seeking health care) – S |
4 to >3.0 points Exemplary Includes a direct quote from patient about presenting problem. |
3 to >2.0 points Distinguished Includes a direct quote from patient and other unrelated information. |
2 to >0.0 points Developing Includes information but information is NOT a direct quote. |
0 points Novice Information is completely missing. |
4 points |
|
Demographics – S |
2 points Exemplary Begins with patient initials, age, race, ethnicity, and gender (5 demographics). |
1.5 points Distinguished Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity, and gender). |
1 points Developing Begins with 3 or less patient demographics (patient initials, age, race, ethnicity, and gender). |
0 points Novice Information is completely missing. |
2 points |
|
History of the Present Illness (HPI) – S |
5 to >3.0 points Exemplary Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity). |
3 to >2.0 points Distinguished Includes the presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity). |
2 to >1.0 points Developing Includes the presenting problem and 4 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity). |
1 to >0 points Novice The presenting problem is not clearly stated and/or there are < 4 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity). |
5 points |
|
Allergies – S |
2 points Exemplary Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy). |
1.5 points Distinguished If allergies are present, student does not list each type of drug, environmental factor, herbal, food, latex name and include severity of allergy OR description of the allergy. |
1 points Developing If allergies are present, student only lists the type of allergy and omits the name of the allergy. |
0 points Novice Information is completely missing. |
2 points |
|
Review of Systems (ROS) – S |
5 to >3.0 points Exemplary Includes a minimum of 3 assessments for each body system, assesses at least 9 body systems directed to chief complaint, AND uses the words “admits” and “denies.” |
3 to >2.0 points Distinguished Includes 3 or fewer assessments for each body system, assesses 5-8 body systems directed to chief complaint, AND uses the words “admits” and “denies.” |
2 to >0.0 points Developing Includes 3 or fewer assessments for each body system, and assesses less than 5 body systems directed to chief complaint, OR student does not use the words “admits” and “denies.” |
0 points Novice Information is completely missing. |
5 points |
|
Vital Signs – O |
2 points Exemplary Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain). |
1.5 points Distinguished Includes at least 6 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain). |
1 points Developing Includes at least 4 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain). |
0 points Novice Information is completely missing. |
2 points |
|
Labs, Diagnostic Tests and Screening Tools – O |
3 points Exemplary During the visit: Includes a list of the labs, diagnostic tests or screening tools reviewed at the visit, values of lab results or screening tools, and highlights abnormal values, OR acknowledges no labs/diagnostic tests were reviewed. |
2 points Distinguished During the visit: Includes a list of the labs, diagnostic tests, or screening tools reviewed at the visit, but does not include the values of lab results or screening tools, but does not highlight abnormal values. |
1 points Developing During the visit: Includes a list of the labs, diagnostic tests, or screening tools reviewed at the visit but does not include the values of the results or highlight abnormal values. |
0 points Novice Information is completely missing. |
3 points |
|
Medications-S |
3 points Exemplary Includes a list of all of the patient reported psychiatric and medical medications and the diagnosis for the medication (including name, dose, route, frequency). |
2 points Distinguished Includes a list of all of the patient reported psychiatric and but omits the medical medications and the diagnosis for the medication (including name, dose, route, frequency). |
1 points Developing Includes a list of some of the patient reported psychiatric and/or medical medications and the diagnosis for the medication (omits the dose, route, frequency of the medications). |
0 points Novice Information is completely missing. |
3 points |
|
Past Medical History-S |
3 points Exemplary Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current. |
2 points Distinguished Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current. |
1 points Developing Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current. |
0 points Novice Information is completely missing. |
3 points |
|
Past Psychiatric History-S |
4 to >3.0 points Exemplary Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), and year of diagnosis. |
3 to >2.0 points Distinguished Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (omits addiction treatment), and year of diagnosis. |
2 to >0.0 points Developing Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), and does not include the year of diagnosis. |
0 points Novice The information is completely missing. |
4 points |
|
Family Psychiatric History-S |
4 to >3.0 points Exemplary Includes an assessment of at least 6 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder, and history of suicidal attempts. |
3 to >2.0 points Distinguished Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder, and history of suicidal attempts. |
2 to >0.0 points Developing Includes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder, and history of suicidal attempts. |
0 points Novice Information is completely missing. |
4 points |
|
Social History-S |
3 points Exemplary Distinguished Includes all 11 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation. |
2 points Distinguished Includes at least 8 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation. |
1 points Developing Includes all 6 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation. |
0 points Novice Information is completely missing. |
3 points |
|
Mental Status Exam-O |
15 to >12.0 points Exemplary Includes all 10 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with detailed descriptions for each area. |
12 to >10.0 points Distinguished Includes all 8 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with detailed descriptions for each area. |
10 to >0.0 points Developing Includes >6 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with some descriptions for each area. |
0 points Novice Includes <3 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) OR detailed descriptions is not included for each area. |
15 points |
|
Primary Diagnoses-A |
11 to >6.0 points Exemplary Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority) using the DSM-5-TR. The correct ICD-10 billing code is used. |
6 to >3.0 points Distinguished Includes a clear outline of the accurate diagnoses addressed at the visit but does not list the diagnoses in descending order of priority using the DSM-5-TR. The correct ICD-10 billing code is used. |
3 to >0.0 points Developing Includes an inaccurate diagnosis as the principal diagnosis. The ICD-10 code is incorrect or missing. |
0 points Novice Information is completely missing. |
11 points |
|
Differential Diagnoses-A |
3 points Exemplary Includes at least 2 differential diagnoses that can be supported by the subjective and objective data provided using the DSM-5-TR. The correct ICD-10 billing code is used. |
2 points Distinguished Includes 1 differential diagnosis that can be supported by the subjective and objective data provided using the DSM-5-TR. The correct ICD-10 billing code is used. |
1 points Developing Includes at least 1 differential diagnosis that is NOT supported by the subjective and objective data. The ICD-10 code is incorrect or missing. |
0 points Novice Information is completely missing. |
3 points |
|
Outcome Labs/Screening Tools – O |
3 points Exemplary After the visit: orders appropriate diagnostic/lab testing or screening tool 100% of the time OR acknowledges “no diagnostic testing or screening tool clinically required at this time.” |
2 points Distinguished After the visit: orders appropriate diagnostic/lab testing 50% of the time OR acknowledges “no diagnostic testing or screening tool clinically required at this time.” |
1 points Developing After the visit, orders appropriate diagnostic testing less than 50% of the time. |
0 points Novice Information is completely missing. |
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