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Psychiatric SOAP Note Template

Psychiatric 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. Refer to the Psychiatric SOAP Note PowerPoint for further detail about each of these sections.

 

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.

Objective                

 

This is where the “facts” are located. Include relevant labs, test results, vitals, and Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…” 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.

Psychotherapy Treatment Plan

 

Include

3 Goals, each goal should have 3 objectives, each objective should have a minimum of 2 interventions;

Goal#1

Objective #1.1

INT#1.1

INT#1.2

INT#1.3

 

Objective 2.1

INT#2.1

INT#2.2

INT#2.3

 

Objective #3.1

INT#3.1

INT#3.2

INT#3.3