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week5 soap note

Demographic Data 

· Patient’s age and patient’s gender identity 

· IT MUST BE HIPAA compliant. 

Subjective 

·
Chief Complaint (CC): 

· Place the patient’s CC complaint in Quotes 

·
History of Present Illness (HPI): 

· Reason for an appointment today. 

· The events that led to hospitalization or clinic visits today.  

· Include symptoms, relieving factors, and past compliance or non-compliance with medications 

· Any adverse effects from past medication use 

· Sleep patterns – number of hours of sleep per day, early wakefulness, inability to initiate sleep, inability to stay asleep, etc. 

· Suicide or homicide thoughts present 

· Any self-care or Activity of Daily Living (ADL) such as eating, drinking liquids, self-care deficits, or issues noted? 

· Presence/description of psychosis (if psychosis, command or non-command) 

·
Past Psychiatric History (PSH):  

· Past psychiatric diagnoses 

· Past hospitalizations 

· Past psychiatric medications use 

· Any non-compliance issues in the past? 

· Any meds that didn’t work for this patient? 

·
Family History of Psychiatric Conditions or Diagnoses: 

· Mother/father, siblings, grandparents, or direct relatives 

·
Social History:  

· Include nutrition, exercise, substance use (details of use), sexual history/preference, occupation (type), highest school achievement, financial problems, legal issues, children, and history of personal abuse (including sexual, emotional, or physical). 

·
Allergies:  

· To medications, foods, chemicals, and others.  

·
Review of Systems (ROS) (Physical Complaints):  

· Any physical complaints by the body system? (Respiratory, Cardiac, Renal, etc.)  

Objective  

·
Mental Status Exam: 

· This is not a physical exam. 

· Mental Status Exam (MSE) 

Assessment (Diagnosis) 

·
Differentials 

· Two (2) differential diagnoses with ICD-10 codes. 

· Must include rationale using DSM-5 Criteria (Required)  

· Why didn’t you pick these as a major diagnosis? 

·
Working Diagnosis 

· Final or working diagnosis (1), with ICD-10 code.  

· Must include rationale using DSM-5 criteria required – Which symptoms/signs in the DSM-5 the patient matches mostly) 

Plan 

·
Treatment Plan (Tx Plan):  

· Pharmacologic:  Include complete information for each medication(s) prescribed 

· Refill Provided:  Include complete information for each medication(s) refilled 

·
Patient Education: 

· Including specific medication teaching points 

· Was the risk versus benefit of the current treatment plan addressed for meds or treatment 

· Risk versus benefit of non-FDA approved for working diagnosis – Off-label use of medication education to patient addressed? 

·
Prognosis: 

· Make Decision for prognosis: Good, Fair, Poor 

· Provide brief statement lending support for or against the decided prognosis. 

·
Therapy Recommendations: 

· Type(s) of therapy recommended. 

·
Referral/Follow-up: 

· Did you recommend follow-up with a Psychiatrist, PCP, or other specialist or healthcare professionals? 

· When is the subsequent follow-up? 

· Include the rationale for the F/U recommendation or referral. 

Reference(s): 

· Include American Psychological Association (APA) formatted references.  

· Include a reference from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) or the accompanying Desk Reference of Diagnostic Criteria from DSM-5. 

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