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.
|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)|
Gender Identifier Note:
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. Patientâ€™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.
(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.
History of ViolenceÂ to Self:Â none reported
History of Violence tÂ o Others: none reported
Mental health treatment historyÂ discussed:
History of outpatient treatment: not reported
Previous psychiatric hospitalizations: not reported
Prior substance abuse treatment: not reported
Trauma history:Â Client does not report history of trauma including abuse, domestic violence, witnessing disturbing events.
Substance Use:Â 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.
Past Psych Med Trials:
Family Medical Hx:
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.
Legal History: no reported/known legal issues, no reported/known conservator or guardian.
Spiritual/Cultural Considerations: none reported.
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, etcâ€¦)
|Verify Patient:Â Name, AssignedÂ Â identificationÂ 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.
, Past Medical and Psychiatric History,
Current Medications, Previous Psych Med trials,
Social History, Family History.
Review of Systems (ROS) â€“ if ROS is negative, â€œROS noncontributory,â€ or â€œROS negative with the exception ofâ€¦â€
|Objective||Vital Signs:Â Stable
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