soap note

Psychiatric SOAP Note Template

Encounter date:  ________________________     

Patient Initials: ______ Gender: M/F/Transgender ____  Age:  _____ Race: _____ Ethnicity ____

Reason for Seeking Health Care: ______________________________________________

HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SI/HI: _______________________________________________________________________________

Sleep:  _________________________________________         Appetite:  ________________________

Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________

Current perception of Health:         Excellent     Good     Fair   Poor

Psychiatric History:

Inpatient hospitalizations:

DateHospitalDiagnosesLength of Stay
     

Outpatient psychiatric treatment:

DateHospitalDiagnosesLength of Stay

Detox/Inpatient substance treatment:

DateHospitalDiagnosesLength of Stay


History of suicide attempts and/or self injurious behaviors: ____________________________________

Past Medical History

  • Major/Chronic Illnesses____________________________________________________
  • Trauma/Injury ___________________________________________________________
  • Hospitalizations __________________________________________________________

Past Surgical History___________________________________________________________

Current psychotropic medications: 

_________________________________________                    ________________________________

_________________________________________                    ________________________________

_________________________________________                    ________________________________

Current prescription medications: 

_________________________________________                    ________________________________

_________________________________________                    ________________________________

_________________________________________                    ________________________________

OTC/Nutritionals/Herbal/Complementary therapy:

_________________________________________                    ________________________________

_________________________________________                    ________________________________

Substance use: (alcohol, marijuana, cocaine, caffeine, cigarettes)

SubstanceAmountFrequencyLength of Use

Family Psychiatric History:  _____________________________________________________

Social History

Lives: Single family House/Condo/ with stairs: ___________ Marital Status:________

Education:____________________________

Employment Status: ______ Current/Previous occupation type: _________________

Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________

Sexual Orientation: _______ Sexual Activity: ____ Contraception Use: ____________

Family Composition: Family/Mother/Father/Alone: _____________________________

Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________

________________________________________________________________________

Health Maintenance

Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____

Exposures:

Immunization HX:

Review of Systems:

General:

HEENT:

Neck:

Lungs:

Cardiovascular:

Breast:

GI:

Male/female genital:

GU:

Neuro:

Musculoskeletal:

Activity & Exercise:

Psychosocial:

Derm:

Nutrition:

Sleep/Rest:

LMP:

STI Hx:

Physical Exam

BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt.   ______ BMI (percentile) _____

General:

HEENT:

Neck:

Pulmonary:

Cardiovascular:

Breast:

GI:

Male/female genital:

GU:

Neuro:

Musculoskeletal:

Derm:

Psychosocial:

Misc.

Mental Status Exam

Appearance:

Behavior:

Speech:

Mood:

Affect:

Thought Content:

Thought Process:

Cognition/Intelligence:

Clinical Insight:

Clinical Judgment:

Significant Data/Contributing Dx/Labs/Misc.

Plan:

Differential Diagnoses

1.

2.

Principal Diagnoses

1.

2.

Plan

Diagnosis #1

Diagnostic Testing/Screening:

Pharmacological Treatment:          

Non-Pharmacological Treatment:

Education:

Referrals:

Follow-up:

Anticipatory Guidance:

Diagnosis #2

Diagnostic Testingg/Screenin:

Pharmacological Treatment:          

Non-Pharmacological Treatment:                                                                                      

Education:

Referrals:

Follow-up:

Anticipatory Guidance:

Signature (with appropriate credentials): __________________________________________

Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________

DEA#:  101010101                          STU Clinic                                   LIC# 10000000

Tel: (000) 555-1234                                                                             FAX: (000) 555-12222

Patient Name: (Initials)______________________________        Age ___________

Date: _______________

RX ______________________________________

SIG:

Dispense:  ___________                                                     Refill: _________________

        No Substitution

Signature: ____________________________________________________________