Posted: October 1st, 2022

Initial Psychiatric Interview/SOAP Note Template

SOAP notes and therapy plan

(600 WORDS)

Assessment the video case: Suicide Assessment of Consumer with initially Delicate Warning Indicators of Suicide

Full a SOAP Note as if you happen to have been the psychotherapist within the video. Then write a one-page abstract that highlights the warning indicators of suicidality within the affected person and why you selected the therapy plan you select in your SOAP Note.

Keep in mind there two elements to this request. When writing the plan for the SOAP word preserve the plan particular to this shopper.

At the least 2 pages, Separate References for every Question Assignment, , APA format, inside final 5 years, together with Doi, ( no web sites)
Initial Psychiatric Interview/SOAP Note Template

There are other ways by which to finish a Psychiatric SOAP (Subjective, Goal, Assessment, and Plan) Note. This can be a template that’s meant to information you as you proceed to develop your model of SOAP within the psychiatric follow setting.

Standards Medical Notes

Knowledgeable Consent Knowledgeable consent given to affected person about psychiatric interview course of and psychiatric/psychotherapy therapy. Verbal and Written consent obtained. Affected person has the power/capability to reply and seems to grasp the danger, advantages, and (Will assessment extra consent throughout therapy plan dialogue)

Subjective Confirm Affected person
Title: C.H
DOB:10/12/2004

Minor: sure
Accompanied by: Father

Demographic: African American

Gender Identifier Note: Male

CC: Latest decline in grades, poor consideration

HPI: Identified with ADHD at age 7 was medicated with concerta 36mg. Cease taking medicine three years in the past when he went from conventional college to on-line college. Has since enrolled again in conventional college and has been having issues concentrating which has led to a decline in grades and having to finish summer time college. Dad would really like the affected person to be began again on medicine ideally Concerta to help with consideration at school.

Pertinent historical past in document and from affected person: At age 7, affected person was began on Concerta 18mg after which elevated to 36mg. Treatment was efficient in growing consideration and sustaining assing grades at school.

Throughout Assessment: Affected person describes their temper as regular, however indicated that point administration and focus has gotten worse in TIME.

Affected person shallowness seems truthful, no reported emotions of extreme guilt,
no reported anhedonia, doesn’t report sleep disturbance, does report change in urge for food and that he eat much less and fewer every day, doesn’t report libido disturbances, doesn’t report change in power,
reported adjustments in focus and reminiscence.

Affected person doesn’t report elevated exercise, agitation, risk-taking behaviors, pressured speech, or euphoria. Affected person doesn’t report extreme fears, however worries so much, no reported panic assaults.
Affected person doesn’t report hallucinations, delusions, obsessions or compulsions. Affected person’s exercise stage, consideration and focus have been noticed to be inside regular limits throughout interview. Affected person doesn’t report signs of consuming dysfunction. There isn’t any current weight reduction or acquire. Affected person doesn’t report signs of a characterological nature.

SI/ HI/ AV: Affected person at present denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent habits, denies inappropriate/unlawful behaviors.

Allergic reactions: NKDFA.
(medicine & meals)

Previous Medical Hx:
Medical historical past: Denies cardiac, respiratory, endocrine and neurological points, together with historical past head damage.
Affected person denies historical past of continual an infection, together with MRSA, TB, HIV and Hep C.
Surgical historical past no surgical historical past reported

Previous Psychiatric Hx:
Earlier psychiatric diagnoses: ADHD
Describes secure course of sickness.
Earlier medicine trials: Risperadol and Concerta

Security considerations:
Historical past of Violence to Self: none reported
Historical past of Violence to Others: none reported
Auditory Hallucinations:
Visible Hallucinations:

Psychological well being therapy historical past mentioned:
Historical past of outpatient therapy: psychotherapy from 2010-2018
Earlier psychiatric hospitalizations: not reported
Prior substance abuse therapy: not reported

Trauma historical past: Consumer doesn’t report historical past of trauma together with abuse, home violence, witnessing disturbing occasions.

Substance Use: Consumer denies use or dependence on nicotine/tobacco merchandise.
Consumer does report prior hashish use however denies abuse of or dependence on ETOH, and different illicit medication.

Present Medicines: No present medicines.
(Contraceptives):
Dietary supplements:

Previous Psych Med Trials: Risperadol and Concerta

Household Medical Hx: None reported

Household Psychiatric Hx: None reported

Social Historical past:
Occupational Historical past: at present unemployed. Denies earlier occupational hx (Excessive College Pupil)
Navy service Historical past: Denies earlier army hx.
Training historical past: accomplished 11th grade and going into 12 grade
Developmental Historical past: no important particulars reported.
(Childhood Historical past embrace in utero if obtainable)
Authorized Historical past: no reported/identified authorized points, no reported/identified conservator or guardian.
Religious/Cultural Concerns: Christian

ROS:
Constitutional: No report of fever or weight reduction.
Eyes: No report of acute imaginative and prescient adjustments or eye ache.
ENT: No report of listening to adjustments or problem swallowing.
Cardiac: No report of chest ache, edema or orthopnea.
Respiratory: Denies dyspnea, cough or wheeze.
GI: No report of stomach ache.
GU: No report of dysuria or hematuria.
Musculoskeletal: No report of joint ache or swelling.
Pores and skin: No report of rash, lesion, abrasions.
Neurologic: Stories occasional complications which might be relieved by OTC Tylenol. No report of seizures, blackout, numbness or focal weak point. Endocrine: No report of polyuria or polydipsia.
Hematologic: No report of blood clots or simple bleeding.
Allergy: No report of hives or allergic response.
Reproductive: No report of great points. (females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, and many others…)

Confirm Affected person: Title, Assigned identification quantity (e.g., medical document quantity), Date of beginning, Cellphone quantity, Social safety quantity, Tackle, Picture.

Embody demographics, chief criticism, subjective info from the affected person, names and relations of others current within the interview.

HPI:

, Previous Medical and Psychiatric Historical past,
Present Medicines, Earlier Psych Med trials,
Allergic reactions.
Social Historical past, Household Historical past.
Assessment of Programs (ROS) – if ROS is destructive, “ROS noncontributory,” or “ROS destructive apart from…”
Goal Very important Indicators: Steady
Temp:
BP: 110/64
HR: 72
R: 17
O2: 100%
Ache: Zero/10
Ht: 6’four
Wt: 140
BMI: 17
BMI Vary: beneath weight

LABS:
Lab findings WNL
Tox display: Unfavourable
Alcohol: Unfavourable
HCG: N/A

Bodily Examination:
MSE:
Affected person is cooperative and conversant, seems with out acute misery, and absolutely oriented x four. Affected person is dressed appropriately for age and season. Psychomotor exercise seems inside regular.
Presents with acceptable eye contact, euthymic have an effect on – full, even, congruent with reported temper of “x”. Speech: spontaneous, regular price, acceptable quantity/tone with no issues expressing self.
TC: no irregular content material elicited, denies suicidal ideation and denies homicidal ideation. Course of seems linear, coherent, goal-directed.
Cognition seems grossly intact with acceptable consideration span & focus and common fund of data.
Judgment seems truthful . Perception seems truthful

The affected person is ready to articulate wants, is motivated for compliance and adherence to medicine routine. Affected person is prepared and in a position to take part with therapy, disposition, and discharge planning.

That is the place the “info” are situated.
Vitals,
**Bodily Examination (if carried out, is not going to be carried out each go to in each setting)
Embody related labs, take a look at outcomes, and Embody MSE, threat Assessment right here, and psychiatric screening measure outcomes.
Assessment DSM5 Analysis: with ICD-10 codes

Dx: – F90.Zero- consideration deficit and hyperactive dysfunction attentive kind
Dx: – R63.6-underweight
Dx: –

Affected person has the power/capability seems to answer psychiatric medicines/psychotherapy and seems to grasp the necessity for medicines/psychotherapy and is prepared to take care of adherent.
Reviewed potential dangers & advantages, Black Field warnings, and options together with declining therapy.
Embody your findings, analysis and differentials (DSM-5 and every other medical analysis) together with ICD-10 codes, therapy choices, and affected person enter relating to therapy choices (if doable), together with obstacles to therapy.

Knowledgeable Consent Potential
Plan

(Note some gadgets could solely be relevant within the inpatient atmosphere)

Pharmacologic interventions: together with dosage, route, and frequency and non-pharmacologic:

• Concerta is a superb possibility for a lot of adolescents who expertise any inattention complaints. I normally begin at 18 mg and transfer to 36mg relying on the necessity to enhance. f/u inside 30 days initially then each 90 days.
• Psychotherapy referral for CBT
Training, together with well being promotion, upkeep, and psychosocial wants
• Significance of medicine adherence
• Mentioned present cannibus use and the way it can intrude with medicine. NRT not indicated.
• Security planning
• Talk about worsening sx and when to contact workplace or report back to ED
Referrals: nutritionist for underweight
Comply with-up, together with return to clinic (RTC) with timeframe and purpose and any labs which might be wanted for subsequent go to 30 days

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

Time spent in Psychotherapy 30 minutes

Go to lasted 60 minutes

Billing Codes for go to:
99214
90833

____________________________________________
PMHNP scholar

Date: 5/30/2022 Time: 1330

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Tags: Initial Psychiatric Interview/SOAP Note Template