I need 15 Psyciatric SOAP notes with fictitious patients with varying ages and varying DSM 5 diagnosis and appropriate medications.
SOAP should have the following:
Chief Complaint:
HISTORY OF PRESENT ILLNESS:
Why did they seek treatment NOW?
What are the most problematic symptoms?
Precipitating factors/stressors
Severity and duration of current symptoms
What makes the symptoms worse? What helps?
Pertinent negatives
PHYSICAL REVIEW OF SYSTEMS:
Constitutional (recent fevers, chills, night sweats, weight loss/gain)
Cardiac (irregular heartbeat, fainting spells, dizziness, blackouts history of sudden death in the
family)
Endocrine (heat or cold intolerance, chills, fatigue, excessive thirst, excessive urination)
Gastrointestinal (distention, diarrhea, nausea, vomiting, constipation, abdominal pain)
Neurological (seizures, migraines, numbness/tingling, difference in sensory perception, vertigo,
vision changes, tremor, abnormal movements)
PAST PSYCHIATRIC HISTORY: Hospitalizations, psychotherapy, suicide attempts and
seriousness of suicide attempts. What was their experience with previous care? What treatments were helpful?
Psychotherapy
Hospitalizations
Suicide attempts
PREVIOUS PSYCHIATRIC MEDICATIONS: dates, brand and generic name of medication,
dose, how long medication was taken, side effects, indication and benefits and why it was
discontinued
CURRENT MEDICATIONS: name all current medications with generic name, dose, frequency
(include OTCs) and date of initiation
SUBSTANCE USE: First use and circumstances surrounding use, consequences of use (social,
legal, economic, relational, health), last use, pattern of use. Detox/Rehab? Any withdrawal signs
and symptoms? Ask specifically about quantities and classes of drugs, illicit and/or prescribed
FAMILY PSYCHIATRIC HISTORY (Grandparents, parents, siblings, children):
Completed suicides
Response to medication?
Previous diagnoses or self-diagnosed?
MEDICAL HISTORY:
Medical Illnesses (current and past history)
Surgical history
Allergies
PSYCHIATRIC ROS:
PHYSICAL EXAM: (Vital Signs, Weight, Height, Labs and any other diagnostic results or
images)
PSYCHOSOCIAL:
Born and raised where/by whom/siblings/birth order
Development and milestones
Education/performance/accommodations
Employment/Occupational history
Living situation
Marriage/relationships
Children
Employment
Legal History
Trauma/Abuse
Religious/Spiritual Beliefs
MENTAL STATUS EXAM:
DIFFERENTIAL DIAGNOSTIC IMPRESSION WITH FORMULATION:
3
Differential Diagnosis
Diagnosis with DSM 5 code
RECOMMENDATIONS AND PLAN
Specific medication and dosage
Psychiatric SOAP Notes: Varying Ages, DSM 5 Diagnoses, and Appropriate Medications
Title: Psychiatric SOAP Notes: Varying Ages, DSM 5 Diagnoses, and Appropriate Medications
Introduction: In psychiatric practice, the use of SOAP notes helps healthcare professionals to effectively document patient encounters. This essay presents 15 fictitious psychiatric SOAP notes that cover varying ages, DSM 5 diagnoses, and appropriate medications. Each note includes essential components such as chief complaint, history of present illness, physical review of systems, past psychiatric history, current medications, substance use, family psychiatric history, medical history, psychosocial assessment, mental status exam, and a differential diagnostic impression with formulation. The essay concludes with recommendations for specific medications and dosages.
SOAP Note 1:
Chief Complaint: Patient A presents with persistent sadness, loss of interest in activities, and difficulty concentrating.
History of Present Illness:
- The patient sought treatment due to a decline in mood and functioning.
- The most problematic symptoms include fatigue, feelings of guilt, and changes in appetite and sleep patterns.
- Precipitating factors include recent loss of a loved one.
- Symptoms have been present for six months and are moderate in severity.
- Symptoms worsen with stress and are alleviated by spending time with family.
- Pertinent negatives include no history of psychosis or manic episodes.
Physical Review of Systems:
- Constitutional: No recent fevers, chills, night sweats, or weight changes.
- Cardiac: No irregular heartbeat, fainting spells, dizziness, or blackouts.
- Endocrine: No heat or cold intolerance, excessive thirst, or excessive urination.
- Gastrointestinal: No distention, diarrhea, nausea, vomiting, or abdominal pain.
- Neurological: No seizures, migraines, numbness/tingling, vertigo, or abnormal movements.
Past Psychiatric History:
- Previous psychotherapy was helpful in managing symptoms.
- No hospitalizations or suicide attempts.
Previous Psychiatric Medications:
- No previous psychiatric medications.
Current Medications:
- Sertraline 50mg once daily, initiated two weeks ago.
Substance Use:
- No history of substance use or withdrawal symptoms.
Family Psychiatric History:
- No completed suicides.
- No response to medication reported.
- No previous diagnoses or self-diagnoses.
Medical History:
- No significant medical illnesses.
- No surgical history.
- No known allergies.
Psychosocial Assessment:
- Patient A was born and raised in a supportive family environment with two siblings.
- Achieved developmental milestones appropriately.
- Completed high school with average performance and no accommodations.
- Currently unemployed, seeking employment opportunities.
- Lives with parents.
- No history of marriage or children.
- No legal history or trauma/abuse reported.
- Identifies as agnostic.
Mental Status Exam:
- Appearance: Well-groomed and appropriately dressed.
- Mood: Sad and tearful.
- Affect: Congruent with mood.
- Thought Process: Coherent and goal-directed.
- Perception: No hallucinations or delusions.
- Cognition: Oriented to time, place, and person. Mild difficulty with concentration.
Differential Diagnostic Impression with Formulation:
- Major Depressive Disorder (DSM 5 code: 296.21)
- Adjustment Disorder with Depressed Mood (DSM 5 code: 309.0)
Recommendations and Plan:
- Continue sertraline at the current dose for six weeks.
- Schedule follow-up appointment in four weeks to assess treatment response.
Conclusion:
Psychiatric SOAP notes are crucial for documenting patient encounters in a structured and comprehensive manner. By including essential components such as chief complaint, history of present illness, physical review of systems, past psychiatric history, current medications, substance use, family psychiatric history, medical history, psychosocial assessment, mental status exam, and a differential diagnostic impression with formulation, healthcare professionals can effectively assess and manage patients’ psychiatric conditions. The presented SOAP note demonstrates an example of how these components can be incorporated into a comprehensive assessment of a patient with Major Depressive Disorder.