Use this SOAP Note and Rx template to complete the Case Study. 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.
Criteria
Clinical Notes
Subjective
Include chief complaint, subjective information from the patient, names and relations of others present in the interview, and basic demographic information of the patient. HPI, Past Medical and Psychiatric History, Social History, Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…”.
Objective
This is where the “facts” are located. Include relevant labs, test results, vitals, and physical exam if performed. Include MSE, risk assessment here, and psychiatric screening measure results.
Assessment
Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment.
Plan
Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options and complimentary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment.
PRESCRIPTION (for student use-Not VALID)
Purdue Global Medical Clinic
15 Medical Clinic Circle
Destination, SS, 00123
Phone: 123 456 7890
Fax: 123 456 7890
PMHNP Student Jane Purdue, APRN
License # SS 17245A
NPI # 1234567899
PATIENT DETAILS:DATE:
NAME
………………Patient Doe……………………………………………………………..…..
DOB …….………………………………………………………..
ADDRESS
……………3515 Admiral Way……………………………………………………………
…………….Destination, SS 00123……………………………………………………..
___________________
Prescriber’s signature
Copy any Case study questions from the instructions and answer here.
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