Description
PURPOSE: The purpose of writing the SOAP note is to practice gathering and presenting information for psychiatric-mental health clients, which differs from that of other disciplines (e.g., Family NP).NOTE: Do not use patient identifiers.Include the amount of time you spent with the client in your summary; you will use this for billing purposes (eventually).Use these documents to write your SOAP note:
Unformatted Attachment Preview
Guidelines for Psych SOAP Note
SOAP Note Content
History of Present Illness (HPI)… includes
identifying information and Chief Complaint
(in quotations); add date of service and
Typhon Case #.
Include only pertinent information as it
relates to the problem.
Points
10
Histories, including pertinent PMHx to
include illnesses, surgeries/hospitalizations.
Family medical history (FMHx), past psych
hx., substance use/abuse hx., developmental
and social hx.; include allergies and current
medications with dosages.
Review of Systems as it pertains to the
presentation symptoms.
Objective Data (i.e., Mental Status Exam)
Diagnosis using DSM-5 criteria with
explanation and rationale
Management, consisting of your
management plan for this encounter.
• You should address WHY are you doing
what you are doing.
• Include medications, treatments,
diagnostic tests if ordered.
• Identify what was discussed or should
have been discussed.
Education, patient education and follow-up
done or could be done.
• Include specific instructions to the client.
(If not done, include what you would
have done).
• Include a goal for the client AND
expectations.
Assessment, including what you might do
differently or not in the care of this client
based on the literature.
• How do clinical guidelines differ from
what was done?
• Include at least one reference no more
than 5 years old and NOT the textbook.
5
5
5
5
10
5
5
Guidelines for Psych SOAP Note
SOAP Note Content
• What is the standard of care for this
diagnosis? Include at least 1 reference.
Use of APA Format (7th ed.)
• This assignment will be held to all
rules set forth in the APA 7th ed.,
including proper formatting for in-text
citations (paraphrased and/or directly
quoted), reference page, and tables,
charts, templates, or graphs.
• Any failure to properly cite
paraphrased or directly quoted
material constitutes an violation of
the College Academic Integrity Policy
(SW-25) and will be processed per the
Academic Integrity Policy.
• Note: Headings can be in SOAP note
format.
Points
TOTAL
60 points
10
SOAP Note 1
9/22/2023
SOAP Note 1
HISTORY OF PRESENT ILLNESS (HPI):
L. T is a 33 y.o. Caucasian male who presented to the clinic today for worsening of his
anxiety and depression with difficulty falling asleep through the night for about a month since he
1
run out of his medications. Symptoms were gradual starting several years ago and rated as
moderate in the past. Patient has history of anxiety, depression, bipolar disorder, mood
instability, insomnia, PTSD. Patient symptoms were well managed with medications, but patient
run out of his prescribed medications while waiting to be seen for this appointment. Patient
recently moved to this city form out of state. Patient reports feeling of sadness, hopelessness, and
lack of motivation to start his days. Patient reports feeling excessively energetic with decreased
need for sleep sometimes but has not feel like that for many years. In the last three months
patient has been extremely worried about everything and is having difficultly controlling his
stress.
Currently, symptoms are causing impairment in day-to-day functioning. Associated
symptoms include anxiety, depression, irritability, and sleep disturbance. Precipitating factors
include recent relocations and worsen of his restless leg syndromes (RLS) the last weeks. Patient
described RLS as incontrollable urge to move, which is accompanied by uncomfortable
sensations in his lower extremities at night in bed when resting. Patient endorses anxiety rated at
8/10 (rated on 0-10 scale), depression rated 5/10 with steady tiredness and lack of motivation.
Patient reports troubles falling asleep with RLS that lasts for a couple of hours, states he stays
asleep. States he has been averaging about 4-5 hours of sleep per night during the week and
sleeps in on the weekend. Patient reports having nightmare related to his time in military. Patient
also report episodes of flashbacks in the last month. Patient denies suicidal and self-harm
thoughts, homicidal thoughts. denies manic cycle symptoms of mood change, poor sleep without
tiredness, irritable, snappy, racing thoughts, increased activity. Patient denies changes in appetite
and denies weight loss or gain. Patient also denies psychosis such as auditory or visual
hallucinations and paranoid thinking. Patient denies chronic or acute pain.
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Date of service: 09/05/2023
Typhon case number: 2483-20230905-001
Time spent with patient: 70 min.
PAST MEDICAL HISTORY (PMH): L.T has a past medical history that include restless leg
syndromes and hypothyroidism.
SURGERIES: L.T denies surgery in the past
HOSPITALIZATIONS: L.T has no surgical history. He was hospitalized at age 23 for acute
manic episode. Patient was diagnosed with bipolar disorder.
FAMILY PSYCHIATRIC HISTORY: Family history includes alcohol abuse in his maternal
grandfather; anxiety disorder in his brother, mother, and sister; Depression in his brother,
mother, and sister; Drug abuse in his father.
PAST PSYCH HX: Past psychiatric history include anxiety, depression, bipolar disorder, mood
instability, insomnia, PTSD.
PAST PSYCHIATRIC MEDICATION REVIEWED
Seroquel 100 mg at night for about 3 months. Patient stopped taking Seroquel because it made
him groggy.
Melatonin 10mg for many years but stopped because it was not effective anymore.
Abilify, patient does not remember the dose but reports feeling like zombie while taking it.
SUBSTANCE USE/ABUSE HISTORY: Patient reports Marijuana (smoking or edible)
occasionally (once every two to three months), first time use was at age 20. The patient denies
alcohol and nicotine use.
DEVELOPMENTAL AND SOCIAL HISTORY: L.T was born and raised in Denver
Colorado. L. T lived with both his parents and siblings until he was 18, his parents were married
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but used to fight a lot he said. L.T was the first born of 4 siblings (2 brothers and 1 sister). L.T
moved out of his family house after high school graduation. Patient recently moved to Omaha
about 4 months ago with his wife and children. Patient met his spouse in high school, but they
didn’t get married until November of 2015. Patient described his marriage as peaceful and happy
blessing. L.T current housing situation is house, where patient lives with spouse (a litigation
attorney), and their 3 kids (daughter 12, son 8 and daughter 7 that are with patient full time). He
works with a company 9-5, similar processes to real estate (has a degree in political science) and
works from home some days. Spouse is an attorney (works with litigations) and just made
partner. Patient is his own legal guardian.
ABUSE AND TRAUMA: Patient reports physical abuse from childhood (abusive parents).
Patient denies childhood sexual abuse. Patient denies any current abuse. Patient reports
witnessing horrifying scenes while on deployment in Iraq.
PROTECTIVE FACTORS: Patient is Christian and believes in God.
SUPPORT SYSTEM: Patient’s wife and children constitute his support system.
MILITARY SERVICE: Yes. Patient served in military (Army branch) for 4 years from 2010 to
2014.
ALLERGIES: Patient is allergic to Sulfa (Sulfonamide Antibiotics). The reaction was skin
rashes.
MEDICATIONS WITH DOSAGES:
•
Trazodone 25-50 mg HS prn sleep
•
Ativan 0.5 mg daily prn anxiety/sleep
•
Lithium CR 900 mg HS for bipolar maintenance
•
Synthroid 50 mcg daily in the morning
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REVIEW OF SYSTEMS:
Vital Signs: Temp 36.5, HR 72, BP 124/65, RR 16, SpO2 99% on room air, Weight 156 lbs.,
Height 5’6’’, BMI 25.18
Constitutional: Denies weight loss or weight gain, fever, or chills. Patient report feeling tired
with lack of energy.
Eyes: Denies vision change or eye discharge, denies hearing change
HENT: Denies nasal congestion, runny nose, post-nasal drainage, or sore throat.
Respiratory: Denies cough or shortness of breath
Cardiovascular: Denies edema, chest pain, or palpitations
GI: Denies change in appetite, abdominal pain, nausea, vomiting, or diarrhea.
GU: Denies dysuria, hematuria, urgency, or urinary frequency
Musculoskeletal: Denies muscle pain or joint pain
Integument: Denies skin lesions such as rash or hives
Neurologic: Denies headache, motor weakness, or sensory changes. Patient reports RLS off and
on for years (prior to starting lithium).
Endocrine: Denies polyuria or polydipsia. patient report history of hypothyroidism
Lymphatic: Denies swollen or painful glands
The following labs were drawn during this visit: lithium level, CMP, TSH, CBC, lipid panel,
Hgb A1c.
MENTAL STATUS EXAM
General Appearance, Attitude, and Behavior: Patient appears age appropriate, appropriately
dressed, appears stated age, poor eye contact, normal motor activity, cooperative, reliable
historian and engages well.
5
Gait and Station: steady
Muscle Strength and Tone: WNL
Mood is anxious and depressed.
Affect is mood congruent.
Language: fluent production
Speech: normal pitch and normal volume, normal rate
Thought Process: goal directed, organized.
Thought Association: logical
Thought Content:
•
Suicidal Ideation: None
•
Homicidal Ideation: none
•
Hallucinations: none
•
Delusions: none
Memory is intact for immediate, recent, and remote recall.
Sensorium and Orientation: alert and oriented to person, place, time/date, and situation
Attention Span & Concentration: appropriate.
Insight: fair
Judgment: fair
Fund of knowledge: average
DIAGNOSES:
1. Bipolar disorder, current episode depressed, moderate ICD 10 F31.32. According to (DSM5; American Psychiatric Association, 2013), L.T meets criteria for this diagnosis due to
currently feeling depressed, sad, hopeless, lack of energy for more than two weeks. Patient
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endorses depression at 5/10 on a scale of 0 (no depression) to 10 (very depressed) and
symptoms are neither mild nor too severe. Patient having at least one episode of mania or
hypomania in their lifetime and currently experiencing a depressive episode as evidenced by
history of hospitalization in the past for mania and being on maintenance treatment for
bipolar. PHQ-9 was 12 and it was used in determining the depression level of this patient.
2. Insomnia, unspecified type ICD 10 G47.00. Patient meets criteria for this diagnosis because
according to (DSM- 5; American Psychiatric Association, 2013), insomnia criteria include
difficulty initiating and maintaining sleep for at least 3 months with impairment of daily
functioning. This patient has been on Trazodone to sleep for years and has been struggling to
fall asleep in the past month when he is out of his medications. This patient:
3. Generalized Anxiety Disorder ICD 10 F41.1. According to (DSM- 5; American Psychiatric
Association, 2013), GAD criteria include:
•
Extreme anxiety or worry that occurs for 6 months or more and creates
impairment in school or work requirements. It may also cause problems with
social relationships.
•
The patient has difficulty controlling the worry or anxiety.
•
The anxiety or worry may also accompany restlessness, complaints of being tired,
problems concentrating, irritability, and difficulty with sleep.
L.T meets criteria for this diagnosis because he has history of anxiety previously managed by
Ativan PRN. He endorses excessive uncontrollable worrying causing sleep disturbances and
functional impairment and he rated anxiety at 8/10 (Scale 0 – 10)
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4. Posttraumatic stress disorder ICD 10 F43.10. L.T meets criteria for this diagnosis because
patient has history of childhood physical abuse, emotional traumatism from war. Patient also
reports having nightmare and flashbacks in the last month.
5. Restless Leg Syndrome ICD 10 G25.81. According to (DSM- 5; American Psychiatric
Association, 2013), L.T meets criteria for RLS because he reports history of on/off restless
leg syndrome untreated and complains of overwhelming urge to move with uncomfortable
sensations in his lower extremities at night in bed. Patient relates his difficulty falling asleep
to RLS. These symptoms are impairing patient’s quality of life.
MANAGEMENT:
1. Start Gabapentin 100 mg HS for RLS.
Many conditions can be associated with sleep disturbance and for this patient RLS is one of
them. Therefore, it is important to address these symptoms to help achieved the goal of better
sleep night. Gabapentin is an anticonvulsive medication that can also be used to treat chronic
RLS. The recommended starting dose is 100 to 300 mg in the evening (one to two hours before
the usual onset of symptoms) and titrating slowly upwards based on response and tolerability
(Silbert, 2023).
2. Start Ramelteon 8 mg HS for insomnia.
Ramelteon was started and trazodone discontinued because patient reported extreme tiredness in
the morning while taking trazodone. According to Neubauer (2023) Ramelteon has agonist
activity at the melatonin MT1 and MT2 receptors, which are prominent in the hypothalamic
suprachiasmatic nucleus (SCN; master circadian rhythm timekeeper) and like melatonin,
ramelteon facilitates sleep onset by decreasing the typical evening SCN-driven arousal (MT1),
and apparently helps to reinforce circadian periodicity (MT2). Ramelteon was proven to be a
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good choice for patient with difficulty falling asleep however, Ramelteon is unlikely to improve
sleep maintenance.
3. Restart Ativan 0.5 mg BID prn anxiety/sleep.
Ativan 0.5 mg twice daily as needed was restarted because patient has reported that Ativan as
needed was effective to manage his anxiety. Patient did not want to try a new anxiety medication
at this time. In addition, patient does not have any history of substance abuse. Lorazepam
(Ativan) belongs to the class of drugs called benzodiazepines and is FDA approved for the shortterm treatment of anxiety. Lorazepam works by binding to benzodiazepine receptors on the
postsynaptic GABA-A ligand-gated chloride channel neuron at several sites within the central
nervous system (CNS) (Ghiasi et al., 2022).
4. Continue Lithium CR 900 mg HS for bipolar maintenance.
Lithium was continued because patient has reported feeling absence of manic episodes or mania
symptoms since his was started on Lithium by his previous psychiatrist. Patient stated that
Lithium was effective at managing his Bipolar symptoms and he would like not to change it at
this time. Plus, Lithium has been the treatment of choice for patients with bipolar disorder and it
is recommended by all relevant guidelines as a first-line treatment for maintenance therapy
(Volkmann et al., 2020).
5. Discontinue Trazodone 25-50 mg HS prn sleep.
6. Referral for therapy.
Psychotherapy is effective in managing many conditions this patient is experiencing such as
PTSD, anxiety, depression, and insomnia. L.T will benefit from CBT to manage his anxiety and
depression, CBT-I (CBT for Insomnia) for his insomnia and Eye movement desensitization and
reprocessing (EMDR) for his PTSD. I had the opportunity to see a patient spectacular progress
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with CBT-I and I think every patient struggling with insomnia must try CBT-I. Research
supports that it is as effective in treating insomnia symptoms as sedative-hypnotics during acute
treatment (4–8 weeks) and is more effective than sedative-hypnotics in the long term (Walker et
al., 2022).
7. Ordered labs lithium level, CMP, TSH, CBC, lipid panel, Hgb A1c.
Lithium level was ordered as part of treatment management. It is recommended to regularly
monitor lithium level in patient taking lithium to avoid lithium toxicity. For this patient, we need
a lithium level as a baseline as the patient is new to us. In addition, long-term treatment with
lithium is associated with a reduction of the GFR and a twofold increased risk of chronic kidney
disease (Volkmann et al., 2020). Lithium use is also associated with lithium may lead to
increased blood calcium and parathyroid hormone levels and increase risk for hypothyroidism.
Therefore, renal function, calcium level, TSH need to be closely monitored. Other labs including
CBC, lipid panel, Hgb A1c were ordered to have an overview on patient health and rule out any
possible medical condition.
EDUCATION: Patient’s informed consent was obtained verbally. Patient was educated on risks,
benefits, side effects and alternatives to treatment regarding medications and treatment
recommendations. Patient was instructed to taking medications as prescribed, discouraged to
taking extra dose or skipping doses. Patient was educated to avoid using alcohol, and illicit
substances while taking medications. Patient was educated on the side effects of Ramelteon with
the most common side effects being somnolence, dizziness, fatigue, nausea, and exacerbation of
insomnia (Neubauer, 2023). It was also discussed with. L.T the side effects of gabapentin such
as somnolence, dizziness, and ataxia (Silbert, 2023). Patient verbalized understanding and
consent for treatment.
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It is specially discussed with patient the process of monitoring of Lithium levels every 23 months for the first six months, then stable monitoring every 6-12 months; plasma levels tests
about 12 hours after last dose. Patient was educated on the importance to monitor kidney
function tests 1-2 times per year. Lithium is associated with weight gain, will monitor weight and
BMI during treatment and evaluate for pre-diabetes, diabetes or dyslipidemia as indicated with
weight gain of >5% of initial weight. Patient was also explained the rationale behind monitoring
thyroid levels one month after starting lithium and annually or more frequently as clinically
indicated. During this visit, it was discussed toxic levels of lithium and signs of toxicity to
include tremor, ataxia, diarrhea, vomiting, sedation, excessive sweating, or diarrhea. L.T was
also educated on side effect of Ativan including sedation, dizziness, weakness, unsteadiness,
depression, amnesia, loss of orientation, headaches, sleep disturbances, low blood pressure
(hypotension) (Craske & Bystrisky, 2023).
Medication refills: Patient was instructed to contact pharmacy for medication refills.
Safety Plan: Patient advised to call the clinic here if has any questions, concerns, side effects of
medications/treatment. In case of worsening of condition, patient was instructed to go to the
nearest emergency room or call 911 for help if has thoughts of self-harm or suicide or homicide.
ASSESSMENT: When it comes to the treatment plan, I agree with mostly all of them except for
one. I understand that Lithium has been working for this patient when it comes to the
maintenance of his bipolar disorder. One of the side effects of lithium therapy is restless leg
syndrome. And even though the patient reported that he was suffering from restless leg
syndrome before even starting lithium, I would discuss with the patient the possibility of
exploring another mood stabilizer such as Lamictal. In fact, Lamotrigine is also a first line drug
in the acute and maintenance treatment of bipolar depression and is often used in treatment of
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bipolar disorder due to more common depressive symptom like this patient (Zhihan et al., 2022).
I would also recommend using Ativan for a short-term (less than 3 months) due risk of
dependence and abuse for the long-term use. I will suggest a non-benzodiazepine anxiolytic such
as hydroxyzine or Buspar to L.T. Overall, patient was provided enough education on his
conditions and their management.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(DSM-5). American Psychiatric Association.
Craske, M., & Bystrisky, A. (2023, July 5). UpToDate. Www.uptodate.com.
https://www.uptodate.com/contents/generalized-anxiety-disorder-in-adults-management
Ghiasi, N., Bhansali, R. K., & Marwaha, R. (2022). Lorazepam. PubMed; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK532890/
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Neubauer, David. “UpToDate.” Www.uptodate.com, 22 Aug. 2023,
www.uptodate.com/contents/pharmacotherapy-for-insomnia-in-adults.
Pandi-Perumal, S. R., Spence, D. W., Verster, J. C., Srinivasan, V., Brown, G. M., Cardinali, D.
P., & Hardeland, R. (2011). Pharmacotherapy of insomnia with ramelteon: safety,
efficacy and clinical applications. Journal of central nervous system disease, 3, 51–65.
https://doi.org/10.4137/JCNSD.S1611
Silbert, M. (2023, July 7). UpToDate. Www.uptodate.com.
https://www.uptodate.com/contents/management-of-restless-legs-syndrome-and-periodiclimb-movement-disorder-in-adults/print
Volkmann, C., Bschor, T., & Köhler, S. (2020). Lithium Treatment Over the Lifespan in Bipolar
Disorders. Frontiers in psychiatry, 11, 377. https://doi.org/10.3389/fpsyt.2020.00377
Walker, J., Muench, A., Perlis, M. L., & Vargas, I. (2022). Cognitive Behavioral Therapy for
Insomnia (CBT-I): A Primer. Klinicheskaia i spetsial’naia psikhologiia = Clinical
psychology and special education, 11(2), 123–137.
https://doi.org/10.17759/cpse.2022110208
Zhihan, G., Fengli, S., Wangqiang, L., Dong, S., & Weidong, J. (2022). Lamotrigine and
Lithium Combination for Treatment of Rapid Cycling Bipolar Disorder: Results From
Meta-Analysis. Frontiers in psychiatry, 13, 913051.
https://doi.org/10.3389/fpsyt.2022.913051
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CLARKSON COLLEGE GRADUATE NURSING PROGRAM
NS 856—Introduction to Psychiatric-Mental Health Nursing
SOAP Note 1—Directions + Rubric
PURPOSE: The purpose of writing the SOAP note is to practice gathering and presenting
information for psychiatric-mental health clients, which differs from that of other disciplines
(e.g., Family NP).
POINTS: 60
DIRECTIONS:
1. Refer to the SOAP note information in Wheeler, p. 107.
2. Refer to the outline in Wheeler, p. 151, Appendix 3.1.
3. Identify a case from your clinical practicum and create a SOAP note for that client.
NOTE: You must use a pseudonym for the client; do not use his or her given name.
4. Include the amount of time you spent with the client in your summary; you will use this
for billing purposes (eventually).
[See rubric, next page.]
CLARKSON COLLEGE GRADUATE NURSING PROGRAM
NS 856—Introduction to Psychiatric-Mental Health Nursing
SOAP Note 1—Directions + Rubric
EVALUATION RUBRIC
*Refer to the Guidelines document for information to include for each criterion.
Criteria
History of Present
Illness (HPI)*
10 points
Complete, concise
summary of pertinent
information, including
Typhon case number
and date
8 points
Well-organized; partial
but accurate summary
of pertinent
information (>80%)
Histories*
Complete and concise
summary of pertinent
information. All aspects
of PMHx, FMHx,
psychiatric, substance
use, medications, and
social history
(5 points)
Complete and concise
summary of systems,
including pertinent
positives and negatives
as they pertain to the
problem
(5 points)
Well-organized; partial
but accurate summary
of pertinent
information (>80%)
(4 points)
Review of Systems
(ROS)*
Well organized; partial
but accurate review of
systems, including
pertinent positives and
negatives as they
pertain to the problem
(4 points)
4 points
Poorly organized and/or
limited summary of
pertinent information
(50-80%); identifying
information missing;
information other than
subjective information
provided
Poorly organized and/or
limited summary of
pertinent information
(50-80%) (2 points)
0 points
Less than 50% of
pertinent information
addressed—OR—is
grossly incomplete
and/or inaccurate
Less than 50% of
pertinent information
addressed—OR—is
grossly incomplete
and/or inaccurate
Poorly organized and/or Less than 50% of
limited review of
pertinent information
systems, including
addressed or is missing
pertinent positives and
negatives as they
pertain to the problem
(50-80%) (2 points)
CLARKSON COLLEGE GRADUATE NURSING PROGRAM
NS 856—Introduction to Psychiatric-Mental Health Nursing
SOAP Note 1—Directions + Rubric
Criteria
Mental Status Exam*
10 points
Complete and concise;
all information included
(5 points)
8 points
Partial information
(>80%); missing a vital
sign or laboratory value
(4 points)
4 points
Poorly organized and
missing more than 1
vital sign or laboratory
value (2 points)
Diagnosis*
Accurate diagnosis and
DSM-5 criteria
(5 points)
Plan/Management*
Specific, appropriate,
and justified
recommendations,
including drug name,
strength, route,
frequency, and duration
of therapy for each
identified problem
Specific client
education, monitoring
parameters, follow-up
plan, and referral (if
applicable); goal and
expectations stated
clearly
(5 points)
Partially accurate
diagnosis and DSM-5
criteria
(4 points)
Mostly complete and
appropriate for each
identified problem
(>80%)
Partially inaccurate
diagnosis and/or DSM-5
criteria
(2 points)
Partially complete
and/or inappropriate
for a few identified
problems (50-80%);
information other than
plan provided
Client education and
monitoring parameters,
follow-up plan, and
referral plan (if
applicable) for > 80% of
identified problems;
partial goal and
expectations stated
(4 points)
Specific client
education, monitoring
parameters, follow-up
plan, and referral plan
(if applicable) for 5080% of identified
problems; weak goal
and/or expectations
stated (2 points)
Plan/Education*
0 points
Less than 50% of the
vital signs are
documented and
laboratory findings are
missing
Incorrect diagnosis
and/or DSM-5 criteria
Less than 50% of
problems have an
appropriate and
complete treatment
plan
Less than 50% of
appropriate
information, including
counseling, monitoring,
referrals, follow-up,
goals, and/or
expectations
CLARKSON COLLEGE GRADUATE NURSING PROGRAM
NS 856—Introduction to Psychiatric-Mental Health Nursing
SOAP Note 1—Directions + Rubric
Criteria
Assessment
10 points
At least 1 reference that
pertains to the problem
(diagnosis); evaluation
of care provided based
on literature findings;
reference date within
last 5 years
(5 points)
Use of APA Format (7th
ed.)
Scholarly sources are
cited and formatted
appropriately according
to APA 7th ed.
guidelines for
paraphrasing and
directly quoted
material; reference
formatting follows APA
7th ed. guidelines
8 points
Complete and accurate
literature review; at
least 1 reference OR
outdated reference.
Evaluation of care
provided based on
literature findings OR
complete an accurate
literature review with
outdated reference
(4 points)
All sources cited but
there are 1 to 3 errors
in in-text citations
and/or on the reference
page
4 points
Reference outdated;
but literature review
accurate and complete
(2 points)
All sources
cited but there
are 4 to 5
errors in intext citations
and/or on the
reference page
(6 points)
0 points
Section missing or
complete or more than
50% of information is
missing or inaccurate
All sources
cited but there
are 6 to 7
errors in intext citations
and/or on the
reference page
(4 points)
All sources
cited but there
are more than
7 errors in intext citations
and/or on the
reference
page—OR—
information
paraphrased or
directly quoted
is plagiarized
(i.e., NOT
CITED).**
TOTAL 60 points
**Cases of plagiarism constitute a violation of the College Academic Integrity Policy (SW-25) and will be processed per that policy.
SOAP Note 1
NS 856
SOAP Note 2
1
Date of service: 10/02/2023
Typhon case number:
Time spent with patient: 70 min.
HISTORY OF PRESENT ILLNESS (HPI):
PAST MEDICAL HISTORY (PMH):
SURGERIES:
HOSPITALIZATIONS:
FAMILY PSYCHIATRIC HISTORY:
PAST PSYCH HX:
PAST PSYCHIATRIC MEDICATION REVIEWED
SUBSTANCE USE/ABUSE HISTORY:
DEVELOPMENTAL AND SOCIAL HISTORY:
ABUSE AND TRAUMA:
PROTECTIVE FACTORS:
SUPPORT SYSTEM:
MILITARY SERVICE:
ALLERGIES:
MEDICATIONS WITH DOSAGES:
REVIEW OF SYSTEMS:
Vital Signs: Temp , HR , BP , RR , SpO2 on room air, Weight , Height, BMI
Constitutional: Denies weight loss or weight gain, fever, or chills. Patient report feeling tired
with lack of energy.
2
Eyes: Denies vision change or eye discharge, denies hearing change
HENT: Denies nasal congestion, runny nose, post-nasal drainage, or sore throat.
Respiratory: Denies cough or shortness of breath
Cardiovascular: Denies edema, chest pain, or palpitations
GI: Denies change in appetite, abdominal pain, nausea, vomiting, or diarrhea.
GU: Denies dysuria, hematuria, urgency, or urinary frequency
Musculoskeletal: Denies muscle pain or joint pain
Integument: Denies skin lesions such as rash or hives
Neurologic: Denies headache, motor weakness, or sensory changes.
Endocrine: Denies polyuria or polydipsia. patient report history of hypothyroidism
Lymphatic: Denies swollen or painful glands
The following labs were drawn during this visit:
MENTAL STATUS EXAM
General Appearance, Attitude, and Behavior: Patient appears age appropriate, appropriately
dressed, appears stated age, poor eye contact, normal motor activity, cooperative, reliable
historian and engages well.
Gait and Station: steady
Muscle Strength and Tone: WNL
Mood is anxious and depressed.
Affect is mood congruent.
Language: fluent production
Speech: normal pitch and normal volume, normal rate
Thought Process: goal directed, organized.
3
Thought Association: logical
Thought Content:
•
Suicidal Ideation: None
•
Homicidal Ideation: none
•
Hallucinations: none
•
Delusions: none
Memory is intact for immediate, recent, and remote recall.
Sensorium and Orientation: alert and oriented to person, place, time/date, and situation
Attention Span & Concentration: appropriate.
Insight: fair
Judgment: fair
Fund of knowledge: average
DIAGNOSES:
MANAGEMENT:
EDUCATION:
ASSESSMENT:
4
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(DSM-5). American Psychiatric Association.
5
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