Posted: September 4th, 2023

Psychiatric SOAP Note Previous Mental Health Treatments

Mental Status Exam Guide

Previous Mental Health Treatments:
Please provide details of any previous mental health treatments, including psychopharmacology, inpatient stabilization, occupational therapy, vocational therapy, marriage/family therapy, group therapy, detoxification, electroconvulsive therapy (ECT), and social services.

Initial Impression:
What is the initial impression of the admitting examiner found in the initial evaluation, triage, or social worker note?

Comparison of Current Status to Initial Impression:
Compare your impression of the patient’s current status to the initial impression. Note any changes or observations.

BRIEF MENTAL STATUS EXAM

Instructions:
Most information can be obtained during an interaction with the patient without asking specific questions. Describe the information observed to support your conclusions.

GENERAL DESCRIPTION

Appearance:
Describe the patient’s appearance, including grooming, manner of dress, level of hygiene, facial expression, remarkable features, height, weight, nutritional status, presence of piercings, tattoos, scars, and the relationship between appearance and age.

Attitude toward Examiner:
Describe the patient’s attitude toward the examiner. Note if the patient has good eye contact, is cooperative, friendly, attentive, interested, frank, seductive, defensive, playful, apathetic, evasive, guarded, etc.

Speech Characteristics:
Describe the qualities of the patient’s speech, including tone, inflection, volume, pronunciation (clear or slurred, mumbling, defects, lisp, stuttering), and speed.

Quantity of Speech:
Assess the quantity of the patient’s speech. Note if the patient verbalizes freely, provides monosyllabic answers, has pressured speech, or is hyperverbal.

Psychomotor Activity:
Evaluate the patient’s psychomotor activity. Note if the patient is experiencing hypoactive psychomotor activity (generalized slowing down of body movements, aimless, purposeless activity, etc.) or hyperactive psychomotor activity (restlessness, agitation, combativeness, wringing of hands, pacing, etc.). Provide a description and conclusion.

MOOD/AFFECT

Mood:
Describe the patient’s mood, which refers to the sustained/consistent emotion that colors their perception of the world. Note if the patient’s mood is sad, labile, euphoric, euthymic, expansive, anhedonic, etc.

Anxiety, Anger, and Depression:
Assess the patient for anxiety, anger, and/or depression. Determine the severity (mild, moderate, or severe) and document findings that support your conclusion. If the patient indicates any suicidal or homicidal thoughts, inquire about plans and report these findings immediately for appropriate intervention.

Affect:
Evaluate the patient’s affect, which refers to the patient’s current emotional reaction inferred from their facial expression. Note the range of the patient’s affect (full or restricted) and provide findings that support your conclusion. Assess if the patient’s affect is appropriate and congruent with the thought content, and provide supporting details. Determine the intensity of the patient’s affect (blunted or flat, shallow, labile, proud, angry, fearful, anxious, guilty, etc.) and note relevant findings. Assess if the patient has difficulty initiating, sustaining, or terminating an emotional response and provide supporting details.

DISORDERS OF THE FORM OF THOUGHT

Thought Process:
Evaluate the patient’s thought process, which refers to the way they put together ideas and associations. Note if the patient is disorganized, coherent, has a flight of ideas, thought blocking, tangential thinking, circumstantial thinking, rambling, evasive responses, or lacks cause and effect relationships and goal-directed thinking.

Thought Content:
Assess the patient’s thought content, which refers to what the patient is thinking and speaking about. Note if the patient has preoccupations with illness, environmental problems, obsessions, compulsions, phobias, suicidal or homicidal thoughts, hypochondriacal symptoms, or specific antisocial urges. If the patient reports any suicidal or homicidal thoughts, inquire about plans and report these findings immediately for appropriate intervention.

Perception:
Evaluate the patient’s perception. Ask specific questions to determine if the patient is experiencing hallucinations (e.g., auditory, visual, olfactory, tactile). Assess if the patient is experiencing illusions, which are misperceptions of a person-environment. Provide a detailed description of the extent and nature of any hallucinations or illusions and explain how you reached this conclusion.

COGNITION

Orientation:
Assess the patient’s orientation to person, place, and time. Determine if the patient’s orientation is good, fair, or poor and provide supporting details.

Memory:
Evaluate the patient’s memory functions, including remote memory, recent past memory, recent memory, and immediate retention and recall.

Remote Memory:
Assess the patient’s remote memory by asking about childhood data, important events, time and place of birth, various schools attended, number of children and their ages and names. Determine if the patient’s remote memory is good, fair, or poor and provide supporting details.

Recent Past Memory:
Ask the patient about their activities yesterday, meals they had (breakfast, lunch, dinner), and assess their recent past memory. Determine if the patient’s recent past memory is good, fair, or poor and provide supporting details.

Recall/Immediate Retention Memory:
Present three words (e.g., pen, apple, watch) and ask the patient to repeat them. Remind the patient that you will ask them to recall these words in a few minutes. Assess the patient’s ability to recall the words immediately. Determine if the patient’s recent memory is good, fair, or poor and provide supporting details.

Recent Memory:
Ask the patient to recall the three words you presented a few minutes ago. Evaluate the patient’s recent memory and determine if it is good, fair, or poor. Provide supporting details.

Concentration and Attention:
Assess the patient’s concentration and attention span. Determine if the patient’s attention span is good, slightly distractible, moderately distractible, or severely distractible.

Abstract/Concrete Thinking:
Evaluate the patient’s abstract and concrete thinking abilities. Use proverbs or similarities to assess abstract thinking. Determine if the patient’s ability to abstract is good, fair, or poor and provide supporting details.

JUDGMENT AND INSIGHT

Judgment:
Assess the patient’s judgment by asking about socially conforming behavior and their understanding of the outcome of their behavior. Determine if the patient’s judgment is good, fair, or poor and provide supporting details.

Insight:
Evaluate the patient’s insight into their illness and their understanding of the outcome. Determine if the patient’s insight is good, fair, or poor and provide supporting details.

BIOLOGICAL DATA

Oxygenation:
Assess the patient’s oxygenation status.

Respiration:
Evaluate the quality and quantity of the patient’s respiration.

Temperature (Temp):
Note the patient’s temperature.

Blood Pressure (B/P):
Measure and record the patient’s blood pressure.

Pulse:
Assess the quality and quantity of the patient’s pulse.

Metabolism

Ingestion:
Inquire about the patient’s nutritional intake, including the number of full meals or snacks per day, meal and snack composition, dietary restrictions, and any inconsistencies in their reported diet.

Digestion:
Ask the patient if they experience any digestion difficulties, such as gas, burping, reflux, acid indigestion, nausea/vomiting, pain, ulcers, bloating, etc.

Elimination:
Inquire about the patient’s elimination patterns, including gas/flatulence, diarrhea, loose stools, constipation, and the frequency and consistency of bowel movements. Check for the presence of blood in the stool.

Sleep Patterns

Quality:
Evaluate the patient’s sleep quality by asking about difficulty falling asleep, difficulty falling back to sleep, tiredness upon awakening, early morning awakening, bad dreams, nightmares, bedwetting, sleepwalking, etc.

Quantity:
Determine the number of hours of sleep the patient needs to feel good in the morning and compare it to the number of hours they currently sleep. Note the patient’s bedtime and wake-up time.

SOCIAL HISTORY

Support System:
Assess the patient’s support system, including family, friends, church, work, etc. Determine the level of support available to the patient.

Occupation:
Inquire about the patient’s occupation, including past and present jobs (employment or volunteer work), and their desires regarding employment. Determine if the patient would like to have a job and explore their preferences.

Spiritual Assessment:
Explore the importance of religion/spirituality in the patient’s life. Determine if their beliefs provide support during stressful situations.

Education:
Ask about the patient’s educational background, including the highest level of school completed and any vocational training programs attended. Inquire if the patient has any aspirations to return to school or pursue vocational training.

Financial Support:
Determine who works in the patient’s household and inquire about other means of financial support available to the household.

Interests:
Explore the patient’s hobbies and activities during spare time. Inquire about their preferences, such as watching TV, exercising, fishing, woodcraft, reading, theater, movies, bowling, walking, running, crossword puzzles, etc.

Note: The above revision maintains the structure and content of the original text, but it has been reformatted for better readability and clarity. The language has been revised to improve coherence and conciseness.

Order | Check Discount

Tags: assignment writers Canada university cost, best dissertation writers China, doctoral dissertation writing service, free AI English assignment writers China, in page paper write an essay