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Tag Archives: Did you recommend follow-up with Psychiatrist PCP or other specialist or healthcare professionals?

March 16, 2025
March 16, 2025

PMHNP Problem Focused SOAP Note

(Use this template for this Assignment)

Demographic Data

  • Patient age and Patient’s gender identity
  • MUST BE HIPAA compliant.

Subjective

Chief Complaint (CC):

  • Place the patient’s CC complaint in Quotes

History of Present Illness (HPI):

 

Problem Focused SOAP Note

 

    • 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, not being able to initiate sleep, not able 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)

Problem Focused SOAP Note

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, history of personal abuse (including sexual, emotional, or physical).

Allergies:

    • to medications, foods, chemicals, and other.

Review of Systems (ROS) (Physical Complaints):

    • Any physical complaints by body system? (Respiratory, Cardiac, Renal, etc.)

Objective

Mental Status Exam:

    • This is not physical exam.
    • Mini-Mental Status Exam (MMSE) – Full exam

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)

Problem Focused SOAP Note

Plan

Treatment Plan (Tx Plan):

  • Pharmacologic: Include full information for each medication(s) prescribed,
  • Refill Provided: Include full information for each medication(s) refilled,

Patient Education:

  • including specific medication teaching points,
  • Was risk versus benefit of 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.

Problem Focused SOAP Note

Referral/Follow-up:

  • Did you recommend follow-up with Psychiatrist PCP or other specialist or healthcare professionals?,
  • When is the subsequent follow-up?,
  • Include 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.
  • Minimum 2 references are required.