Week5 soapnote

Demographic Data · Patient’s age and patient’s gender identity · IT MUST BE HIPAA compliant. Subjective · Chief Complaint (CC): · Place the patient’s CC complaint in Quotes · History of Present Illness (HPI): · Reason for an appointment today. · The events that led to hospitalization or clinic visits today. · Include symptoms, relieving factors, and past compliance or non-compliance with medications · Any adverse effects from past medication use · Sleep patterns – number of hours of sleep per day, early wakefulness, inability to initiate sleep, inability to stay asleep, etc. · Suicide or homicide thoughts present · Any self-care or Activity of Daily Living (ADL) such as eating, drinking liquids, self-care deficits, or issues noted? · Presence/description of psychosis (if psychosis, command or non-command) · Past Psychiatric History (PSH): · Past psychiatric diagnoses · Past hospitalizations · Past psychiatric medications use · Any non-compliance issues in the past? · Any meds that didn’t work for this patient? · Family History of Psychiatric Conditions or Diagnoses: · Mother/father, siblings, grandparents, or direct relatives · Social History:  · Include nutrition, exercise, substance use (details of use), sexual history/preference, occupation (type), highest school achievement, financial problems, legal issues, children, and history of personal abuse (including sexual, emotional, or physical). · Allergies: · To medications, foods, chemicals, and others. · Review of Systems (ROS) (Physical Complaints): · Any physical complaints by the body system? (Respiratory, Cardiac, Renal, etc.) Objective · Mental Status Exam: · This is not a physical exam. · Mental Status Exam (MSE) Assessment (Diagnosis) · Differentials · Two (2) differential diagnoses with ICD-10 codes. · Must include rationale using DSM-5 Criteria (Required) · Why didn’t you pick these as a major diagnosis? · Working Diagnosis · Final or working diagnosis (1), with ICD-10 code. · Must include rationale using DSM-5 criteria required – Which symptoms/signs in the DSM-5 the patient matches mostly) Plan · Treatment Plan (Tx Plan): · Pharmacologic: Include complete information for each medication(s) prescribed · Refill Provided: Include complete information for each medication(s) refilled · Patient Education: · Including specific medication teaching points · Was the risk versus benefit of the current treatment plan addressed for meds or treatment · Risk versus benefit of non-FDA approved for working diagnosis – Off-label use of medication education to patient addressed? · Prognosis: · Make Decision for prognosis: Good, Fair, Poor · Provide brief statement lending support for or against the decided prognosis. · Therapy Recommendations: · Type(s) of therapy recommended. · Referral/Follow-up: · Did you recommend follow-up with a Psychiatrist, PCP, or other specialist or healthcare professionals? · When is the subsequent follow-up? · Include the rationale for the F/U recommendation or referral. Reference(s): · Include American Psychological Association (APA) formatted references. · Include a reference from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) or the accompanying Desk Reference of Diagnostic Criteria from DSM-5.

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