The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice. Â
2
Initial Psychiatric Interview
Student’s name
Institution affiliation
Course
Instructor’s name
Date
Initial Psychiatric Interview/SOAP Note Template
Criteria |
Clinical Notes |
Informed Consent |
Patient was alert, oriented x3 and provided verbal consent to participate in the assessment. |
Subjective |
Verify Patient Name: DB DOB: 50-year-old African American female Minor: No Accompanied by: Patient was unaccompanied Demographic: N/A Gender Identifier Note: Female CC: “I have been feeling stable and I’m taking all my medications” HPI: DB is a 50-year-old African American female presenting for a mental health assessment. She reports taking all of her medications and states that her mood is stable. She reports sleeping and appetite are ok. She is currently attending a methadone program 3 days per week and reports taking 47 mg of methadone daily. DB was alert and oriented x3 during assessment, had proper eye contact, and denied any SI/HI or auditory hallucinations. Pertinent history in record and from patient: Patient has a past diagnosis of schizoaffective disorder, bipolar type. During assessment: The patient reports taking all of her medications, sleeping and appetite are okay, and attending a methadone program 3 days per week. Patient reports taking 47 mg of methadone daily, denies any SI/HI or auditory hallucinations, and states her mood is stable SI/ HI/ AV: Patient denies any suicidal or homicidal ideation, auditory or visual hallucinations. Allergies: No allergies reported Past Medical History: No medical history reported Medical history: Denies any past medical issues. Past Psychiatric History: Patient has been previously diagnosed with schizoaffective disorder bipolar type. She reports previous medication trials and has no history of violence to self or others. Previous psychiatric diagnoses: schizoaffective disorder, bipolar type. Patient describes stable mood. |
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