- Students will be required to complete one SOAP (psych) note on a patient seen in the practicum setting each week.
- These need to follow the guidelines for writing SOAP notes (S = Subjective, O = Objective, A = Assessment, P = Plan) and include relevant history, physical findings, assessment, and interventions.
- Student is required to submit one SOAP NOTE on the assigned patients in order to receive grade.
- Find Template for SOAP Note in the syllabus OR under TEMPLATES on the left hand navigator of blackboard.
PLEASE USE BELOW
Sample template DO YOUR PSYCH SOAP NOTES
- Student Name: _____________________________________________
- SOAP Note #___________Source of Information:
- Patient Information
- Gender
- Height and Weight
- Marital status
- Occupation
- Current medication
- Past Psychiatric medication
- Allergies
- Chief complaint: describe the reason for the visit and chief complaint
- Describe history of present illness, including analysis of symptoms
- Medical history
- Psychiatric history (age of onset, diagnosis, previous treatments, hospitalization)
- Family history
- Psychosocial/Developmental History
- Substance Use History
- Current or Past Legal History
- Current or Past Truma
- Current or Past Abuse
- Review of Systems (no significant issues revealed, CV, Renal, GI, Hepatic, CNS, GU, CA, Metabolic, Pulm, GYN, HIV)
- Mental Staus exam
- Screening tests/symptom scales Performed
- Strengths/Limitations
- Include any objective data you have now, including labs
- Assessment:
- Identify diagnosis, including differential diagnosis and rationale
- Case Formulation
- Plan:
- List plan of care, including medication (Evidence Based Practice) and rationale
- Describe any needed lab work with rationale
- Identify alternatives to this plan
- Referrals
- How soon should the patient return for follow-up and why?
- Was this patient an appropriate patient for a nurse practitioner? Is a nurse practitioner the
- appropriate provider of follow-up care for this patient?
- Was this a health care encounter that required consultation or collaboration with another
- health care provider?
- If yes, to whom should the patient be referred? Is this type of provider available in the
- community?
- Education:
- What education does this patient/family need?
- What community resources are available in the provision of care for this client?
- References:
- List references in APA style (more than 2 is required; one reference must be a journal
- using evidence-based practice, no more than 1 website reference, references should be no
- more than 5 years old)
0 comments