Posted: September 7th, 2024

Initial Psychiatric Interview/SOAP Note Template

SOAP notes and treatment plan

(600 WORDS)

Review the video case: Suicide assessment of Client with initially Subtle Warning Signs of Suicide

https://youtu.be/P2a9102jifM

Complete a SOAP Note as if you were the psychotherapist in the video. Then write a one-page summary that highlights the warning signs of suicidality in the patient and why you chose the treatment plan you choose in your SOAP Note.

Remember there two parts to this request. When writing the plan for the SOAP note keep the plan specific to this client.

At least 2 pages, Separate References for each question, , Help write my thesis – APA format, within last five years, including Doi, ( no websites)
Initial Psychiatric Interview/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.

Criteria Clinical Notes

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)

Subjective Verify Patient
Name: C.H
DOB:10/12/2004

Minor: yes
Accompanied by: Father

Demographic: African American

Gender Identifier Note: Male

CC: Recent decline in grades, poor attention

HPI: Diagnosed with ADHD at age 7 was medicated with concerta 36mg. Stop taking medication 3 years ago when he went from traditional school to online school. Has since enrolled back in traditional school and has been having problems concentrating which has led to a decline in grades and having to complete summer school. Dad would like the patient to be started back on medication preferably Concerta to assist with attention in school.

Pertinent history in record and from patient: At age 7, patient was started on Concerta 18mg and then increased to 36mg. Medication was effective in increasing attention and maintaining assing grades in school.

During assessment: Patient describes their mood as normal, but indicated that time management and concentration 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 report change in appetite and that he eat less and less each day, does not report libido disturbances, does not report change in energy,
reported changes in concentration and memory.

Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. Patient does not report excessive fears, but worries a lot, no reported panic attacks.
Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity level, attention and concentration were observed to be within normal limits during interview. 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.

Allergies: NKDFA.
(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: ADHD
Describes stable course of illness.
Previous medication trials: Risperadol and Concerta

Safety concerns:
History of Violence to Self: none reported
History of Violence to Others: none reported
Auditory Hallucinations:
Visual Hallucinations:

Mental health treatment history discussed:
History of outpatient treatment: psychotherapy from 2010-2018
Previous psychiatric hospitalizations: not reported
Prior substance abuse treatment: not reported

Trauma history: Client does not report history of trauma including abuse, domestic violence, witnessing disturbing events.

Substance Use: Client denies use or dependence on nicotine/tobacco products.
Client does report prior cannabis use but denies abuse of or dependence on ETOH, and other illicit drugs.

Current Medications: No current medications.
(Contraceptives):
Supplements:

Past Psych Med Trials: Risperadol and Concerta

Family Medical Hx: None reported

Family Psychiatric Hx: None reported

Social History:
Occupational History: currently unemployed. Denies previous occupational hx (High School Student)
Military service History: Denies previous military hx.
Education history: completed 11th grade and going into 12 grade
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: Christian

ROS:
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: Reports occasional headaches that are relieved by OTC Tylenol. 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, etc…)

Verify Patient: Name, Assigned identification 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.

HPI:

, Past Medical and Psychiatric History,
Current Medications, Previous Psych Med trials,
Allergies.
Social History, Family History.
Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…”
Objective Vital Signs: Stable
Temp:
BP: 110/64
HR: 72
R: 17
O2: 100%
Pain: 0/10
Ht: 6’4
Wt: 140
BMI: 17
BMI Range: under weight

LABS:
Lab findings WNL
Tox screen: Negative
Alcohol: Negative
HCG: N/A

Physical Exam:
MSE:
Patient is cooperative and conversant, appears without acute distress, and fully oriented x 4. Patient is dressed appropriately for age and season. Psychomotor activity appears within normal.
Presents with appropriate eye contact, euthymic affect – full, even, congruent with reported mood of “x”. Speech: spontaneous, normal rate, appropriate volume/tone with no problems expressing self.
TC: no abnormal content elicited, denies suicidal ideation and denies homicidal ideation. Process appears linear, coherent, goal-directed.
Cognition appears grossly intact with appropriate attention span & concentration and average fund of knowledge.
Judgment appears fair . Insight appears fair

The patient is able to articulate needs, is motivated for compliance and adherence to medication regimen. Patient is willing and able to participate with treatment, disposition, and discharge planning.

This is where the “facts” are located.
Vitals,
**Physical Exam (if performed, will not be performed every visit in every setting)
Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results.
Assessment DSM5 Diagnosis: with ICD-10 codes

Dx: – F90.0- attention deficit and hyperactive disorder attentive type
Dx: – R63.6-underweight
Dx: –

Patient has the ability/capacity appears to respond to psychiatric medications/psychotherapy and appears to understand the need for medications/psychotherapy and is willing to maintain adherent.
Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment.
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.

Informed Consent Ability
Plan

(Note some items may only be applicable in the inpatient environment)

Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic:

• Concerta is an excellent option for many adolescents who experience any inattention complaints. I usually start at 18 mg and move to 36mg depending on the need to increase. f/u within 30 days initially then every 90 days.
• Psychotherapy referral for CBT
Education, including health promotion, maintenance, and psychosocial needs
• Importance of medication adherence
• Assignment help – Discussed current cannibus use and how it can interfere with medication. NRT not indicated.
• Safety planning
• Assignment help – Discuss worsening sx and when to contact office or report to ED
Referrals: nutritionist for underweight
Follow-up, including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit 30 days

☒ > 50% time spent counseling/coordination of care.

Time spent in Psychotherapy 30 minutes

Visit lasted 60 minutes

Billing Codes for visit:
99214
90833

____________________________________________
PMHNP student

Date: 5/30/2022 Time: 1330

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