Description

Initial Psychiatric 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  the ability/capacity to respond and appears to  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 .

Patient self-esteem appears , , 

, ,  ,  , ,

.

Patient .  Patient . 

Patient .  Patient’s .  Patient  symptoms of eating disorder. There is . Patient  symptoms of a characterological nature.

SI/ HI/ AV: Patient currently  suicidal ideation,  SIBx,  homicidal ideation,  violent behavior,  inappropriate/illegal behaviors.

Allergies: .

(medication & food)

Past Medical Hx: 

Medical history: 

Patient .

Surgical history 

Past Psychiatric Hx:

Previous psychiatric diagnoses: . 

Describes  course of illness. 

Previous medication trials: .

Safety concerns: 

History of Violence to Self:  

History of Violence to Others: 

Auditory Hallucinations:

Visual Hallucinations:

Mental health treatment history discussed: 

History of outpatient treatment:  

Previous psychiatric hospitalizations:  

Prior substance abuse treatment:  

Trauma history: Client 

Substance Use: Client  

Client 

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 .  

Military service History: Denies previous military hx.

Education history:  completed HS and vocational certificate 

Developmental History: 

            (Childhood History)

Legal History: , . 

Spiritual/Cultural Considerations: .

ROS:

Constitutional:  .  

Eyes:  .  

ENT:    

Cardiac:  .  

Respiratory:  .  

GI:  .  

GU.  

Musculoskeletal:    

Skin.  

Neurologic:  .  Endocrine:  .  

Hematologic:    

Allergy:   

Reproductive: . (females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…)

Instruction Files