Posted: May 25th, 2023

Psychiatric SOAP Note Template

Psychiatric SOAP Note Template

Encounter date: ________________________

Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____

Reason for Seeking Health Care: ______________________________________________

HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
SI/HI: _______________________________________________________________________________

Sleep: _________________________________________ Appetite: ________________________
Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________

Current perception of Health: Excellent Good Fair Poor
Psychiatric History:
Inpatient hospitalizations:
Date Hospital Diagnoses Length of Stay

Outpatient psychiatric treatment:
Date Hospital Diagnoses Length of Stay

Detox/Inpatient substance treatment:
Date Hospital Diagnoses Length of Stay

History of suicide attempts and/or self injurious behaviors: ____________________________________
Past Medical History
• Major/Chronic Illnesses____________________________________________________
• Trauma/Injury ___________________________________________________________
• Hospitalizations __________________________________________________________

Past Surgical History___________________________________________________________
Current psychotropic medications:

_________________________________________ ________________________________
_________________________________________ ________________________________
_________________________________________ ________________________________

Current prescription medications:

_________________________________________ ________________________________
_________________________________________ ________________________________
_________________________________________ ________________________________

OTC/Nutritionals/Herbal/Complementary therapy:

_________________________________________ ________________________________
_________________________________________ ________________________________

Substance use: (alcohol, marijuana, cocaine, caffeine, cigarettes)

Substance Amount Frequency Length of Use

Family Psychiatric History: _____________________________________________________

Social History
Lives: Single family House/Condo/ with stairs: ___________ Marital Status:________
Education:____________________________
Employment Status: ______ Current/Previous occupation type: _________________
Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________
Sexual Orientation: _______ Sexual Activity: ____ Contraception Use: ____________
Family Composition: Family/Mother/Father/Alone: _____________________________
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________
________________________________________________________________________
Health Maintenance
Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____
Exposures:
Immunization HX:

Review of Systems:
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:

Physical Exam

BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (percentile) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.

Mental Status Exam
Appearance:
Behavior:
Speech:
Mood:
Affect:
Thought Content:
Thought Process:
Cognition/Intelligence:
Clinical Insight:
Clinical Judgment:

Plan:
Differential Diagnoses
1.
2.
Principal Diagnoses
1.
2.
Plan
Diagnosis #1
Diagnostic Testing/Screening:
Pharmacological Treatment:
Non-Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:

Diagnosis #2
Diagnostic Testing/SScreening
Pharmacological Treatment:
Non-Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:

Signature (with appropriate credentials): __________________________________________

Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________

DEA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)______________________________ Age ___________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________ Refill: _________________
No Substitution
Signature: ____________________________________________________________

Complete the Soap Note about a pediatric patient less than 13 year- old, Use the template

Includes at least 4 references

_________________________-

Subjective:

Chief Complaint:
History of Present Illness:
Review of Systems:
Objective:

Physical Examination:
General:
Vital Signs:
Growth Parameters:
HEENT:
Cardiovascular:
Respiratory:
Abdominal:
Musculoskeletal:
Neurological:
Developmental Assessment:
Assessment:

Diagnosis/Differential Diagnosis:
Diagnostic Tests:
Clinical Impression:
Growth and Developmental Assessment:
Plan:

Treatment/Management:
Medications:
Procedures:
Therapies/Interventions:
Patient/Family Education:
Follow-up:
Referrals:
Anticipatory Guidance:
References:

Reference 1
Reference 2
Reference 3
Reference 4
Remember to tailor the SOAP note to the specific patient and include relevant information based on their history, symptoms, and examination findings.

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