Description
Week 3: Problem-Focused SOAP NoteA psychiatric diagnosis on an adult patientSubmit a Problem-Focused SOAP note here for grading. You must use an actual patient from your clinical practicum. Review the rubric for more information on how your assignment will be graded. Be sure to use the SOAP note template for your program and view the rubric associated with your program for details on how your assignment will be graded.
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PMHNP Problem-Focused SOAP Note
(Use this template for this Assignment)
Demographic Data
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Patient age and Patient’s gender identity
MUST BE HIPAA compliant.
Subjective
Chief Complaint (CC):
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Place the patient’s CC complaint in Quotes
History of Present Illness (HPI):
o Reason for an appointment today.
o The events that led to hospitalization or clinic visits today.
o Include symptoms, relieving factors, and past compliance or non-compliance
with medications
o Any adverse effects from past medication use
o Sleep patterns – number of hours of sleep per day, early wakefulness, not
being able to initiate sleep, not able to stay asleep, etc.
o Suicide or homicide thoughts present
o Any self-care or Activity of Daily Living (ADL) such as eating, drinking
liquids, self-care deficits or issues noted?
o Presence/description of psychosis (if psychosis, command or non-command)
Past Psychiatric History (PSH):
o Past psychiatric diagnoses
o Past hospitalizations
o Past psychiatric medications use
o Any non-compliance issues in the past?
o Any meds that didn’t work for this patient?
Family History of Psychiatric Conditions or Diagnoses:
o Mother/father, siblings, grandparents, or direct relatives
Social History:
o Include nutrition, exercise, substance use (details of use), sexual
history/preference, occupation (type), highest school achievement, financial
problems, legal issues, children, history of personal abuse (including sexual,
emotional, or physical).
Allergies:
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to medications, foods, chemicals, and other.
Review of Systems (ROS) (Physical Complaints):
o Any physical complaints by body system? (Respiratory, Cardiac, Renal, etc.)
Objective
Mental Status Exam:
o This is not physical exam.
o Mini-Mental Status Exam (MMSE) – Full exam
Assessment (Diagnosis)
Differentials
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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
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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):
o Pharmacologic: Include full information for each medication(s) prescribed
o Refill Provided: Include full information for each medication(s) refilled
Patient Education:
o including specific medication teaching points
o Was risk versus benefit of current treatment plan addressed for meds or
treatment
o Risk versus benefit of non-FDA approved for working diagnosis – Off-label use
of medication education to patient addressed?
Prognosis:
o Make Decision for prognosis: Good, Fair, Poor
o Provide brief statement lending support for or against the decided prognosis.
Therapy Recommendations:
o Type(s) of therapy recommended.
Referral/Follow-up:
o Did you recommend follow-up with Psychiatrist, PCP, or other specialist or
healthcare professionals?
o When is the subsequent follow-up?
o Include rationale for the F/U recommendation or referral.
Reference(s):
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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.
Minimum 2 references are required.
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