Initial Psychiatric Interview/SOAP Note Template
|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)|
DOB: not provided
Accompanied by: self
Gender Identifier Note: Female
CC: â€œhusband poisoned me and I am going to get fired from my job for breaching securityâ€
HPI: An individual of the feminine gender presents themselves as a patient. Bipolar disorder has run in the client’s family. She seemed to be suffering from serious cases of both anxiety and despair. She had begun to experience delusions and other symptoms of dementia. The complaining patient claimed her spouse was poisoning her and that she would be fired for violating security procedures at work. We were able to determine that she was severely delusional after consulting with her social worker, her workplace, and her family. The person was on Effexor.
Pertinent history in record and from patient: Bipolar
During assessment: Patient is delussional and cannot express herself logicall.
Patient seemed to be suffering from serious cases of both anxiety and despair.
Patient is hallucinating . A deviation from typical behavior in the patient’s energy, focus, and concentration levels was noted. .
SI/ HI/ AV: famiy says that the patient shows signs of suicidal ideation and violent behavior.
(medication & food)
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: Bipolar
Describes stable course of illness.
Previous medication trials: Effexor
History of ViolenceÂ to Self:none reported
History of Violence tÂ o Others: none reported
Auditory Hallucinations: present
Mental health treatment history discussed:
History of outpatient treatment: reported
Previous psychiatric hospitalizations: not reported
Priorsubstance abuse treatment: not reported
Trauma history: Client reveals no history of traumatic experiences (such as abuse, domestic violence, or exposure to upsetting events).
Substance Use: nor reported
Client does not report abuse of or dependence on ETOH, and other illicit drugs.
Current Medications: Effexor.
Past Psych Med Trials: Bipolar
Family Medical Hx: not repported
Family Psychiatric Hx: not reported
Substance use â€“not repoted
Psychiatric diagnoses/hospitalization-not reported
Occupational History: currently unemployed.
Military service History:Denies previous military hx.
Education history: completed HS and vocational certificate
Developmental History: no significant details reported.
(Childhood History include in utero if available)
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 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: Stable
BMI Range: Heathy weight
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