Psychopharma (SOAP NOTE)

Assignment 1: Introduction to the PMHNP SOAP Note

Introduction
The PMHNP SOAP note is a tool utilized to guide clinical reasoning to assess, diagnosis, and develop a treatment plan for a patient based on information presented and current evaluation of the patient. These notes serve as an important source of information about the health status of the patient and can be used to communicate this status to other health care professionals.

Instructions

Review the following resources: (See attachments)
SOAP Note Presentation (PowerPoint)
SOAP Note Presentation Transcript
SOAP Note Template (Word)
Complete the SOAP Note Questionnaire and submit to this assignment.
Background: I am currently enrolled in the Psych Mental Health Nurse Practitioner Program, I am a Registered Nurse, and I work in a Psychiatric Hospital.

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.

CG&AM&BF_10/10/18

EVALUATING AND SUSTAINING CHANGE FROM EBP