S.o.a.p. Note Template For Psychiatry printable pdf download

Date and Time

S.O.A.P. note template for psychiatry (use black ink)

Symptoms

Course

Subjective:

Collateral information

Stresses

Staff observations: agitation, sleep log, cooperation, behavior

Medications: name, dose, route, frequency, duration, therapeutic and side effects, compliance

Other treatments: ECT (treatment #, and as with medications), psychotherapy

Objective:

◊

Appearance: gait ____, posture ____, clothes ____,

grooming,

mileage

General behavior: mannerisms ____, gestures ____, psychomotor activity ____, expression ____,

◊

eye contact,

able to follow commands/requests,

compulsions

◊

Attitude:

cooperative,

hostile,

defensive,

open,

secretive,

evasive,

suspicious,

apathetic,

◊

easily distracted,

focused, etc.

◊

LOC:

vigilant,

alert,

drowsy,

lethargic,

stuporous,

asleep,

comatose,

confused,

fluctuating, etc.

◊

Attention:

can attend,

can concentrate,

distractible,

digit span,

DLROW,

calculations

◊

Orientation:

person,

place,

time,

situation

◊

Memory:

immediate,

recent,

remote

Intellectual: fund of knowledge ____, vocabulary ____

MMSE: __ points out of 30 achieved, missing the following tasks ____

◊

Speech: volume/tone (

loud,

soft,

monotone,

weak,

strong), rate (

fast,

slow,

normal,

pressured),

◊

amount (

talkative,

spontaneous,

expansive,

paucity,

poverty), fluency/rhythm (

slurred,

clear,

◊

with appropriately placed inflections,

hesitant,

with good articulation,

aphasic)

◊

Mood (inquired):

depressed,

euthymic,

elevated,

euphoric,

irritable,

anxious, etc.

◊

Affect (observed):

appropriate to situation,

consistent with mood,

congruent with thought content,

◊

fluctuations (

labile,

even), range (

broad,

restricted), intensity (

blunted,

flat,

normal),

◊

quality (

sad,

angry,

hostile,

indifferent,

euthymic,

dysphoric,

detached,

elated,

◊

euphoric,

anxious,

animated,

irritable)

◊

Thought process/form:

linear,

goal-directed,

circumstantial,

tangential,

loose associations,

◊

incoherent,

evasive,

racing,

thought blocking,

perseveration,

neologisms

◊

Thought content:

delusions (type:

paranoid/persecutory,

grandiose,

somatic,

religious,

bizarre,

◊

nihilistic,

thought insertion,

thought withdrawal,

thought broadcasting),

ideas of reference,

◊

magical thinking,

illusions/hallucinations (type:

auditory,

visual,

somatic,

olfactory,

◊

gustatory,

command,

conversation,

commentary),

suicide/homicide (elaborate further:

◊

active,

passive,

hopelessness,

plan,

detailed plan,

partially executed plan,

method available,

◊

impulsivity,

command hallucinations,

intention,

contracting),

phobias (type:

social,

◊

agoraphobia,

specific/simple),

obsessions

◊

Insight/Judgement:

aware of problem/role,

abstract (

similarities,

proverbs),

understand facts,

◊

draw conclusions,

problem solving

Laboratory & other tests

Assessment: Working primary diagnosis, current differential, other diagnoses

DSM-IV Axis I:

DSM-IV Axis II:

DSM-IV Axis III:

Diagnostic: obtain collateral information, further observation or questioning, tests, etc.

Plan:

Specific treatment: based upon diagnosis, e.g., medication titration, how many more ECT sessions, etc.

General treatment: reduce stresses, environmental modification, symptomatic (e.g., insomnia), education

Disposition: next source of care, follow-up, back-up plans

Print your name, title (e.g., MS3), pager number, and sign

S.o.a.p. Note Template For Psychiatry

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