Roch week 4 soap case study
Initial Psychiatric Interview/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.
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Criteria |
Clinical Notes |
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Informed Consent |
Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion) |
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Subjective |
Verify Patient Name: Joshua Age: 12 Minor: Yes Accompanied by: Grandmother Demographics: White HPI: presents with a history of increased irritability, angry outbursts, poor sleep, and poor concentration. According to his grandmother, his behavior has been declining recently with the recent introduction of the younger sister to the home, with more sources of jealousy and defiance. Past Medical and Psychiatric History Joshua possesses a rich trauma history such as being neglected during childhood, abused physically, and lacking attachment because of being taken out of parental care. He was diagnosed with oppositional defiant disorder (ODD) and ADHD recently. In the academic field, Joshua is about two years behind in reading and does not like remedial reading but likes the art class. He does not have suicidal or homicidal ideation. Grandmother states that she feels overburdened and unequivocal with school involvement because of her trauma history. |
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Verify Patient: Name, Assigned Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview. HPI: Past Medical and Psychiatric History, Current Medications, Previous Psych Med trials, Allergies. Social History, Family History. Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…” |
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Objective |
Joshua was well dressed, awake, and oriented. Mood was congruent with an irritable effect. There were a normal rate and tone of speech. The line of thought was linear and there was no sign of psychosis. There was loss of attention and concentration. The judgment and insight were also equitable. None of the abnormal motor activities. No reported vitals. No current medications. |
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This is where the “facts” are located. Vitals,
Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results. |
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Assessment |
Primary diagnosis: • Attention-Deficit/Hyperactivity Disorder, Combined Presentation (F90.2) Oppositional Defiant Disorder (F91.3) is a commonly recognized psychiatric disorder. Other Specified Trauma- and Stressor-Related Disorder (F43.8). The symptoms of Joshua can be explained by the emotional dysregulation as a result of the trauma in combination with ADHD and environmental stressors. Academic and caregiver stress enhance functional impairment. Patient has the ability/capacity appears to respond to psychiatric medications/psychotherapy and appears to understand the need for medications/psychotherapy and is willing to maintain adherent. Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment. |
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Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along Informed Consent Ability |
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Plan (Note some items may only be applicable in the inpatient environment) |
· Introduce trauma-focused cognitive behavioral therapy (TF-CBT). · Refer to psychiatric examination with regard to possible stimulant/non-stimulant ADHD medication. · Proposal school evaluation on IEP/504 plan. · Educate psychoeducation and make referral to family support services. · Promote good habits, sleep hygiene and positive reinforcement. · 4-week follow-up to check on the progress of symptoms and participation in treatment. |
