Description
Please upload a case scenario that pertains to Anxiety, Obsessive compulsive disorder or specific phobias.
Please submit a term paper with a cover page and content page.
Your paper should cover the points presented below. This assignment is SafeAssign for originality.
Thank you.
Psychiatric SOAP Note Template
Criteria
Clinical Notes
Informed Consent
Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained.
Please select one choice from below statement:
___ Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion).
___ Patient doesn’t have the ability/capacity to respond and appears to not understand the risk, benefits, and (Will review additional consent during treatment plan discussion)
Subjective Data
Verify Patient: Name, Assigned identification number (e.g., medical record number), Date of birth, Phone number, age, marital status, Gender, ethnicity.
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
Verify Patient Name and DOB:
Minor: Accompanied by:
Chief Complaint (CC):
“in patient’s own words” reason for visit-restate in case formulation
History of Present Illness (HPI):
PQRST or OLDCARTS related to the presenting problem.
Focus includes: precipitating factors
current/recent stressors
reason for seeking help now.
Pertinent history in record and from patient: X
During assessment: Patient describes their mood as X and indicated it has gotten worse in TIME.
Patient self-esteem appears fair, no reported feelings of excessive guilt, no reported anhedonia, does not report sleep disturbance, does not report change in appetite, does not report libido disturbances, does not report change in energy, no reported changes in concentration or memory.
Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. Patient does not report excessive fears, worries or panic attacks. Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a characterological nature.
SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, and denies inappropriate/illegal behaviors.
Past Medical Hx:
Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury.Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C.Surgical history no surgical history reported.
Past Psychiatric Hx:
Previous psychiatric diagnoses: none reported.
Describes course of illness if any. _____________________________
Allergies: NKDFA.(medication & food)
Social History, Family History. Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…
Safety concerns:
History of Violence to Self: none reported
History of Violence to Others: none reported
Auditory Hallucinations: none reported
Visual Hallucinations: none reported
Trauma history:
Client does not report history of trauma including abuse, domestic violence, witnessing disturbing events.
Substance Use:
Client denies use or dependence on nicotine/tobacco products. Client does not report abuse of or dependence on ETOH, and other illicit drugs.
Past Psych Med Trials:
Current Psych Medications:
Family Psychiatric Hx:
Substance use: not reported
Suicides: not reported
Psychiatric diagnoses/hospitalization: not reported
Developmental diagnoses: not reported
Others: not reported
Social History:
Occupational History: currently unemployed. Denies previous occupational hx Military service History: Denies previous military hx.
Education history: completed HS and vocational certificate
Developmental History: (Childhood History): no significant details reported
Legal History: no reported/known legal issues, no reported/known conservator or guardian.
Spiritual/Cultural Considerations: none reported.
ROS:
Constitutional: No report of fever or weight loss.
Eyes: No report of acute vision changes or eye pain.
ENT: No report of hearing changes or difficulty swallowing.
Cardiac: No report of chest pain, edema or orthopnea.
Respiratory: Denies dyspnea, cough or wheeze.
GI: No report of abdominal pain.
GU: No report of dysuria or hematuria.
Musculoskeletal: No report of joint pain or swelling.
Skin: No report of rash, lesion, abrasions.
Neurologic: No report of seizures, blackout, numbness or focal weakness. Endocrine: No report of polyuriaor polydipsia.
Hematologic: No report of blood clots or easy bleeding.
Allergy: No report of hives or allergic reaction.
Reproductive: No report of significant issues.
(females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…)
Pain:________________
Objective Data
This is where the “facts” are located. Vitals, **Physical Exam (if performed, will not be performed every visit in every setting) Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results.
Vital Signs:
Ht:_________________
Wt:_________________
BMI: _______________
BMI Range:__________
LABS:
Lab findings: WNL
Tox screen: Negative
Alcohol: Negative
HCG: N/A
Risk assessment: suicide/violence
Mental Status Examination (MSE)
a) Appearance:
b) Behavior and psychomotor activity
c) Consciousness
d) Orientation
e) Memory
f) Concentration and attention
g) Intellectual functioning
h) Speech and language
i) Perceptions
j) Thought processes
k) Thought content
l) Suicidality or homicidal
m) Mood
n) Affect
o) Judgment
p) Insight
q) Reliability
Psychiatric Review of System (Psych ROS)
a) Anxiety
b) Mania
c) Depression
d) Schizophrenia
e) Panic attacks
f) PTSD
g) OCD
h) ADHD
i) Eating disorders
j) Personality Disorders
Diagnostic testing:
PHQ-9, psychiatric assessment
Assessment
Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment.
Informed Consent Ability
Impression formulation:
DSM5 Diagnosis: with ICD-10 codes:
Differential Diagnosis:
Dx: –
Dx: –
Dx: –
Patient has the ability/capacity appears to respond to psychiatric medications/psychotherapy and appears to have the need for medications/psychotherapy and is willing to maintain adherent. Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment.
Clinical Plan
Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options and complimentary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment and include patient education.
Inpatient:
Psychiatric. Admits to X as per HPI.
Estimated stay 3-5 days
Patient is found to be very anxious and aggressive behavior.
Patient likely poses a high-risk harm to self and harm risk to others at this time. Patient has abnormal perceptions and it appear to be responding to internal stimuli.
Pharmacologic interventions / treatment:
Including dosage, route, and frequency and non-pharmacologic:
Education: including health promotion, maintenance, and psychosocial needs:
Psychoeducation
Mindfulness and Relaxation:
Importance of medication
Discussed current tobacco use. NRT indicated.
Safety planning
Discuss worsening sx and when to contact office or report to ED
> 50% time spent counseling/coordination of care.
Time spent in Psychotherapy: 18 minutes
Visit lasted: 55 minutes
Referrals:
Psychotherapy referral for CBT
Endocrinologist for diabetes
Other
Follow-up:
including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit 2 weeks
References
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