week7 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.