[Solved] soap Note

Assignment Prompt & Instructions

– 2 years ago

**files (1)**

– ## SOAPNoteTemplate-1.docx

**## SOAPNoteTemplate-1.docx**

**PMHNP Problem-Focused SOAP Note**

(Use this template for this Assignment)

**Demographic Data**

· Patient age and Patient’s gender identity

· MUST BE HIPAA compliant.

**Subjective**

**Chief Complaint (CC):**

· Place the patient’s CC complaint in Quotes

**History of Present Illness (HPI):**

·
**Reason for an appointment today.**

· The events that led to hospitalization or clinic visits today.

· Include symptoms, relieving factors, and past compliance or non-compliance with medications

· Any adverse effects from past medication use

· Sleep patterns – number of hours of sleep per day, early wakefulness, not being able to initiate sleep, not able to stay asleep, etc.

· Suicide or homicide thoughts present

· Any self-care or Activity of Daily Living (ADL) such as eating, drinking liquids, self-care deficits or issues noted?

· Presence/description of psychosis (if psychosis, command or non-command)

**Past Psychiatric History (PSH)**:

· Past psychiatric diagnoses

· Past hospitalizations

· Past psychiatric medications use

· Any non-compliance issues in the past?

· Any meds that didn’t work for this patient?

**Family History of Psychiatric Conditions or Diagnoses:**

· Mother/father, siblings, grandparents, or
direct relatives

**Social History:**

· 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:**

· to medications, foods, chemicals, and other.

**Review of Systems (ROS) (Physical Complaints)**:

· Any physical complaints by body system? (Respiratory, Cardiac, Renal, etc.)

**Objective**

**Mental Status Exam:**

· This is not physical exam.

· Mini-Mental Status Exam (MMSE) – Full exam

**Assessment (Diagnosis)**

**Differentials**

· 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**

· 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):**

· Pharmacologic: Include full information for each medication(s) prescribed

· Refill Provided: Include full information for each medication(s) refilled

**Patient Education:**

· including specific medication teaching points

· Was risk versus benefit of current treatment plan addressed for meds or treatment

· Risk versus benefit of non-FDA approved for working diagnosis – Off-label use of medication education to patient addressed?

**Prognosis:**

· Make Decision for prognosis: Good, Fair, Poor

· Provide brief statement lending support
**_for_** or
**_against_** the decided prognosis.

**Therapy Recommendations:**

· Type(s) of therapy recommended.

**Referral/Follow-up:**

· Did you recommend follow-up with Psychiatrist, PCP, or other specialist or healthcare professionals?

· When is the subsequent follow-up?

· Include rationale for the F/U recommendation or referral.

**Reference(s):**

· 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.

**## SOAPNoteTemplate-1.docx**

**PMHNP Problem-Focused SOAP Note**

(Use this template for this Assignment)

**Demographic Data**

· Patient age and Patient’s gender identity

· MUST BE HIPAA compliant.

**Subjective**

**Chief Complaint (CC):**

· Place the patient’s CC complaint in Quotes

**History of Present Illness (HPI):**

·
**Reason for an appointment today.**

· The events that led to hospitalization or clinic visits today.

· Include symptoms, relieving factors, and past compliance or non-compliance with medications

· Any adverse effects from past medication use

· Sleep patterns – number of hours of sleep per day, early wakefulness, not being able to initiate sleep, not able to stay asleep, etc.

· Suicide or homicide thoughts present

· Any self-care or Activity of Daily Living (ADL) such as eating, drinking liquids, self-care deficits or issues noted?

· Presence/description of psychosis (if psychosis, command or non-command)

**Past Psychiatric History (PSH)**:

· Past psychiatric diagnoses

· Past hospitalizations

· Past psychiatric medications use

· Any non-compliance issues in the past?

· Any meds that didn’t work for this patient?

**Family History of Psychiatric Conditions or Diagnoses:**

· Mother/father, siblings, grandparents, or
direct relatives

**Social History:**

· 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:**

· to medications, foods, chemicals, and other.

**Review of Systems (ROS) (Physical Complaints)**:

· Any physical complaints by body system? (Respiratory, Cardiac, Renal, etc.)

**Objective**

**Mental Status Exam:**

· This is not physical exam.

· Mini-Mental Status Exam (MMSE) – Full exam

**Assessment (Diagnosis)**

**Differentials**

· 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**

· 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):**

· Pharmacologic: Include full information for each medication(s) prescribed

· Refill Provided: Include full information for each medication(s) refilled

**Patient Education:**

· including specific medication teaching points

· Was risk versus benefit of current treatment plan addressed for meds or treatment

· Risk versus benefit of non-FDA approved for working diagnosis – Off-label use of medication education to patient addressed?

**Prognosis:**

· Make Decision for prognosis: Good, Fair, Poor

· Provide brief statement lending support
**_for_** or
**_against_** the decided prognosis.

**Therapy Recommendations:**

· Type(s) of therapy recommended.

**Referral/Follow-up:**

· Did you recommend follow-up with Psychiatrist, PCP, or other specialist or healthcare professionals?

· When is the subsequent follow-up?

· Include rationale for the F/U recommendation or referral.

**Reference(s):**

· 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.