Initial Psychiatric Interview/SOAP Note Template

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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.

 

Criteria Clinical Notes
   
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)
Subjective Verify Patient

Name:

DOB:

 

Minor:

Accompanied by:

 

Demographic:

 

Gender Identifier Note:

 

CC:

 

HPI:

 

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, denies inappropriate/illegal behaviors.

 

Allergies: NKDFA.

(medication & food)

 

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 stable course of illness.

Previous medication trials: none reported.

 

Safety concerns:

History of Violence to Self: none reported

History of Violence t o Others: none reported

Auditory Hallucinations:

Visual Hallucinations:

 

Mental health treatment history discussed:

History of outpatient treatment: not reported

Previous psychiatric hospitalizations: not reported

Prior substance abuse treatment: not 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.

 

Current Medications: No current medications.

(Contraceptives):

Supplements:

 

Past Psych Med Trials:

 

Family Medical Hx:

 

Family Psychiatric Hx:

Substance use

Suicides

Psychiatric diagnoses/hospitalization

Developmental diagnoses

 

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: no significant details reported.

(Childhood History include in utero if available)

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 polyuria or 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…)

 
Verify Patient: Name, Assigned  identification number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo.

 

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…”

  
Objective Vital Signs: Stable

Temp:

BP:

HR:

R:

O2:

Pain:

Ht:

Wt:

BMI:

BMI Range:

 

LABS:

Lab findings WNL

Tox screen: Negative

Alcohol: Negative

HCG: N/A

 

 

Physical Exam:

MSE:

Patient is cooperative and conversant, appears without acute distress, and fully oriented x 4. Patient is dressed appropriately for age and season. Psychomotor activity appears within normal.

Presents with appropriate eye contact, euthymic affect – full, even, congruent with reported mood of “x”. Speech: spontaneous, normal rate, appropriate volume/tone with no problems expressing self.

TC: no abnormal content elicited, denies suicidal ideation and denies homicidal ideation. Process appears linear, coherent, goal-directed.

Cognition appears grossly intact with appropriate attention span & concentration and average fund of knowledge.

Judgment appears fair . Insight appears fair

 

The patient is able to articulate needs, is motivated for compliance and adherence to medication regimen. Patient is willing and able to participate with treatment, disposition, and discharge planning.

 

 
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.

  
Assessment DSM5 Diagnosis: with ICD-10 codes

 

Dx: –

Dx: –

Dx: –

 

 

 

 

 

 

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.
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

  
Plan

 

(Note some items may only be applicable in the inpatient environment)

 

  

Inpatient:

Psychiatric. Admits to X as per HPI.

Estimated stay 3-5 days

 

Safety Risk/Plan: Patient is found to be stable and has control of behavior. Patient likely poses a minimal risk to self and a minimal risk to others at this time.

Patient denies abnormal perceptions and does not appear to be responding to internal stimuli.

 

Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic:

 

· No changes to current medication, as listed in chart, at this time

· or…Zoloft is an excellent option for many women who experience any menstrual cycle complaints. I usually start at 50 mg and move to 100 week 6-8. f/u within 2 weeks initially then every 6-8 weeks.

· Psychotherapy referral for CBT

Education, including health promotion, maintenance, and psychosocial needs

· Importance of medication

· Discussed current tobacco use. NRT not indicated.

· Safety planning

· Discuss worsening sx and when to contact office or report to ED

Referrals: endocrinologist for diabetes

Follow-up, including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit 2 weeks

 

 

☒ > 50% time spent counseling/coordination of care.

 

Time spent in Psychotherapy 18 minutes

 

Visit lasted 55 minutes

 

Billing Codes for visit:

XX

XX

XX

 

 

____________________________________________

NAME, TITLE

 

 

 

Date: Click here to enter a date. Time: X

Therapy Modality Focus Points

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Therapy Modalities

Therapy Modality Focus Points

Week X

 

 

Therapy Modality:

 

Creator:

 

Therapy used for what DSM5 Diagnoses:

(support with APA reference)

 

Emphasis of Therapy Modality:

 

Goals of Therapy Modality:

 

Notes:

 

 

 

 

References

Mental Status Examination

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  • Review the Learning Resources and consider the insights they provide on comprehensive, integrated psychiatric assessment. Watch the Mental Status Examination B-6 and Simulation Scenario-Adolescent Risk Assessment videos.
  • Watch the YMH Boston Vignette 5 video and take notes; you will use this video as the basis for your Discussion post.

 

Based on the YMH Boston Vignette 5 video, post answers to the following questions:

  • What did the practitioner do well? In what areas can the practitioner improve?
  • At this point in the clinical interview, do you have any compelling concerns? If so, what are they?
  • What would be your next question, and why?

Then, address the following. Your answers to these prompts do not have to be tailored to the patient in the YMH Boston video.

  • Explain why a thorough psychiatric assessment of a child/adolescent is important.
  • Describe two different symptom rating scales that would be appropriate to use during the psychiatric assessment of a child/adolescent.
  • Describe two psychiatric treatment options for children and adolescents that may not be used when treating adults.
  • Explain the role parents/guardians play in assessment.

Support your response with at least three peer-reviewed, evidence-based sources and explain why each of your supporting sources is considered scholarly. Attach the PDFs of your sources.

Choose from one of the three trauma topics listed below and prepare a presentation related to trauma and clinical practice. The presentation should be 10-15 slides in length. You are not required to complete a voice over for this presentation.

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Choose from one of the three trauma topics listed below and prepare a presentation related to trauma and clinical practice. The presentation should be 10-15 slides in length. You are not required to complete a voice over for this presentation.

  1. What is the impact of different restraints in relation to trauma? (physical or pharmacological)
  2. What is the relationship between trauma and homelessness (and other social determinants of health)?
  3. What is the correlation between trauma and substance abuse?

Your Assignment should:

  • follow the conventions of Standard English (correct grammar, punctuation, etc.);
  • be well ordered, logical, and unified, as well as original and insightful;
  • display superior content, organization, style, and mechanics; and;
  • use APA formatting and citation style.

n your presentation cover the following information:

  1. Title Slide
  2. What is the definition of trauma?
    1. Who is vulnerable to trauma?
  3. How can trauma be experienced on the intergenerational level and over the individual and family lifespan?
  4. Pathophysiology of Trauma
  5. How do social determinants of health correlate to the effects of trauma?
  6. S/Sx of Trauma
  7. What is the difference between trauma therapy and trauma-informed care?
  8. What is a trigger and how would you recognize that someone is experiencing trauma-related distress?
  9. How might a person with a history of trauma have behavior that could be interpreted as “noncompliance” or non-adherence?
  10. Special trauma topic: one from the 3 choices listed above.
  11. Conclusion
  12. References

Each week you will be given a prompt to write a reflective journal assignment that will allow you to investigate areas for clinical preparation in psychiatric mental health. 

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Each week you will be given a prompt to write a reflective journal assignment that will allow you to investigate areas for clinical preparation in psychiatric mental health. The reflective journal should abide by APA writing standards, include a minimum of one reference in APA format, and be a minimum of 250 words.

Review video about Adverse Childhood Experience

Estimated Time to Complete: 16 minutes

Review the article related to the ACEs study:

Review Tool Kit:

What are the main components of trauma-informed care and why is the ACEs model of screening so important in primary care and psychiatric mental health care for ALL patients? Discuss the ACEs instrument tool as it related to clinical practice.

HPI: 1 week from inpatient care to current partial inpatient care daily individual psychotherapy session and extended daily group sessions

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Patient Name: XXX

MRN: XXX

 

Date of Service: 01-27-2020

 

Start Time: 10:00 End Time: 10:54

 

Billing Code(s): 90213, 90836

(be sure you include strictly psychotherapy codes or both E&M and add on psychotherapy codes if prescribing provider visit)

 

Accompanied by: Brother

 

CC: follow-up appt. for counseling after discharge from inpatient psychiatric unit 2 days ago

 

HPI: 1 week from inpatient care to current partial inpatient care daily individual psychotherapy session and extended daily group sessions

 

S- Patient states that he generally has been doing well with depressive and anxiety symptoms improved but he still feels down at times. He states he is sleeping better, achieving 7-8 hours of restful sleep each night. He states he feels the medication is helping somewhat and without any noticeable side-effects.

Crisis Issues: He states he has no suicide plan and has not thought about suicide since the recent attempt. He states has no access to prescription medications, other than the fluoxetine. He believes the classes he participated in while inpatient have helped him with coping mechanisms.

Reviewed Allergies: NKA

Current Medications: Fluoxetine 10mg daily

ROS: no complaints

 

O-

Vitals: T 98.4, P 82, R 16, BP 122/78

PE: (not always required and performed, especially in psychotherapy only visits)

Heart- RRR, no murmurs, no gallops

Lungs- CTA bilaterally

Skin- no lesions or rashes

Labs: CBC, lytes, and TSH all within normal limits

 

Results of any Psychiatric Clinical Tests: BAI=34

 

MSE:

Gary Davis, a 36-year-old white male, was disheveled and unkempt on presentation to the outpatient office. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age. During the interview, he was attentive and calm. He was impatient, but polite in his interactions with this examiner. Mr. Davis reported that today was the best day of his life, because he had decided he was going to be better and start his own company. His affect was labile, but appropriate to the content of his speech (i.e., he became tearful when reporting he had “bogeyed number 15” in gold yesterday). His speech was loud, pressured at times then he would quickly gain composure to a more neutral tone. He exhibited loosening of associations and flight of ideas; he intermittently and unpredictably shifted the topic of conversation from golf, to the mating habits of geese, to the likelihood of extraterrestrial life. Mr. Davis described grandiose delusions regarding his sexual and athletic performance. He reported no auditory hallucinations. He was oriented to time and place. He denied suicidal and homicidal ideation. He refused to participate in intellectual- or memory-related portions of the examination. Reliability, judgment, and insight were impaired.

 

A – with (ICD-10 code)

Differential Diagnoses:

1. choose 3 differential diagnoses

2.

3.

Definitive Diagnosis:

Major Depressive Disorder, recurrent, without psychotic features F33.4

Generalized Anxiety Disorder F41.1

 

P- Continue Fluoxetine increasing dose to 20mg.

 

Continue outpatient counseling: partial inpatient program continued with individual and group sessions

 

Non-pharmacological Tx: Psychotherapy Modality used: CBT

Pharmacological Tx: (be specific and give detailed Rx information)

Education: discussed smoking cessation

Reviewed medication side effects and adherence importance

Follow-up: in one week or earlier if any depressive symptoms worsen.

Referrals: none at this time

Based on the learning materials covered in the course, what psychotherapy modalities do you hope to learn in depth to incorporate into your PMHNP practice and why?

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Based on the learning materials covered in the course, what psychotherapy modalities do you hope to learn in depth to incorporate into your PMHNP practice and why?

APA style 1 page

Create your own PDP

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Create your own PDP

  1. Build a Professional Development Plan for  yourself, focused on your selected competency
  2. Decide on a Foundation/Practice Dimension  and a single Competency
  3. What are your strengths and challenges
  4. Assign yourself a proficiency level from the  Rubrics
  5. Select 1-3 KSAs from TAP 21 to target
  6. Define the goal you want to achieve
  7. Create a list of activities to be completed
  8. Identify how progress will be measured
  9. Determine a deadline date for each activity.

Professional Development Plan

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Professional Development Plan

Staff name: Counselor A Supervisor: Supervisor B Date: January 16, 2021

Foundation/Practice Dimension: PD V, Counseling Element: Counseling Families, Couples, and Significant Others

Competency to be addressed and page number from TAP 21: Page 116-Competency # 93: Describe and summarize the client’s behavior within

the group to document the client’s progress and identify needs and issues that may require a modification on the treatment plan.

Strengths: Conducts very comprehensive initial assessments to guide the treatment plan/ treatment of clients in individual sessions.

Challenges/Concerns: Difficulty in recognizing when the needs of the individual are different from the needs of the group.

________________________________________________________________________________________________________________________

Present level of proficiency from rating forms

1 2 3 4

Level of proficiency to be achieved with this learning plan

1 2 3 4

Target date to complete the plan:

02/28/2021

What is the issue to

be addressed?

Goal

What is to be accomplished?

(measurable/behavioral)

Activities necessary to

achieve the goal

What will be done?

Metrics

How will progress be measured? Target Completion Date

Knowledge:

Situations in which

significant differences

between individual

and group goals

require changing either

the individual’s goals

or the groups focus.

1. Recognition of the

need to change the tx

plan of the individual

based on the

individual’s behavior.

2. Will articulate this

recognition in

supervision citing the

behaviors that

suggest a need to

reassess.

1. Counselor A will

receive Family

Therapy

Supervision as well

as individual

supervision with

current supervisor.

2. Counselor will

rewrite a treatment

plan for the

individual while in

supervision, with

support from the

supervisor.

3.

1.During supervision, counselor

and supervisor will review past

treatment plans with newly

revised treatment plans to note

differences between plans.

2. In reviewing plans, client

outcome and progress will be

noted to demonstrate change due

to updated tx plan.

1. Bi weekly review of charts-02/21/21

2. Family Therapy supervision will occur until 3/21/21 and be reassessed to determine if there is a need to continue.

 

 

What is the issue to

be addressed?

Goal

What is to be accomplished?

(measurable/behavioral)

Activities necessary to

achieve the goal

What will be done?

Metrics

How will progress be measured? Target Completion Date

Skill:

Documenting the

client’ group behavior

that has implications

for treatment planning.

1. Noting the family

dynamics and how

they will impact the

sessions and overall

outcomes.

1. Attend a training on

family dynamics,

roles, and

expectations in a

family system

disrupted by

substance use

disorder/s.

1. Discuss information

taken from training with

supervisor and how

counselor sees it playing

out in family sessions.

2. Note observations in

chart, and steps taken to

address the implications

for tx planning and

overall session outcomes

and progress.

1. Bi-weekly review

of charts.

Attitude:

Appreciation for

individual differences

in progress toward

treatment goals and

use of group

intervention.

Articulate the many factors

that determine why people

differ in progress and

outcomes during the same

family sessions based on

anecdotal experience and

then based on research.

Reconcile the differences

between the two.

Write a short paper on

what the research

demonstrates regarding

differences in progress and

outcomes.

Discuss the paper in supervision

and discuss personal beliefs and

how they are alike and differ

from the research being cited in

the paper,

Discuss how a lack of

appreciation of the differences

can be counterproductive in

treatment sessions.

01/24/21-individual

supervision

01/31/21-group

supervision

Additional comments: Counselor A has recently begun facilitating family/significant others therapy groups in our agency. She has expressed some

concerns on the transition, notably a focus that extends beyond the individual and the implications for treatment planning and treatment. Counselor A

came to the supervisor to request this opportunity as Counselor A is a student of systems theory and recognize families for the systems they are. She

recognizes that she does not have a full appreciation of the differences toward progress in a group setting and states that it may be due, in part, to her

lack of understanding of dynamics in a group setting in therapy. She is willing to learn and open to feedback when needed.

Supervisor signature: ___________________________Date: _______ Counselor: ___________________________________ Date______

Date for “re-observation” to assess performance: 04/15/21

 

 

Results:

Counselors continuing clinical assessments and tx plans show a marked improvement when documenting the need for individual treatment plans

rather than a plan that addresses the “group” as the only client in the room. Her notes document when the “assigned” roles, and “rules” of the group

present themselves during the session, the impact they have on the session, and how she responds to them or uses them as an intervention or

“teachable moment. She admits to still “falling prey” to some of her negative beliefs as to why some family members do not do as well as others. She

utilizes individual supervision to address her concerns and reports that she finds group supervision helpful as; it offers her the opportunity to learn

from others who also run family/significant other/ group therapy sessions.

Next Appointment: _______________________

Impact of trauma on children and or adolescents;

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pick one or the other and write about

  • Impact of trauma on children and or adolescents;
  • Culture and Trauma;

attach is outline

 

conduct a literature review relating to your topic. Your literature review must include at least 7 professional journal articles. It may also include information obtained from chapters in books on your topic. Your review should be in APA style, a minimum of 7 pages (not including the title and reference pages), typed and double-spaced. The paper shall include an introduction to the subject matter and the subject’s importance to the understanding of trauma. (Rubric is posted on Bright Space)