PMHNP Clinical SOAP
Initial 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.
|
Criteria |
Clinical Notes |
|
Informed Consent |
The grandma of the patient gave consent after being told about the mental interview and treatment choices. Getting both verbal and written permission. The patient seems to understand what the treatment will do for them and its risks. During the treatment plan talk, more consents will be looked over. |
|
Subjective |
Verify Patient Name: Joshua DOB: July 12, 2012 Minor: Accompanied by: Grandmother Demographic: 12-year-old male Gender Identifier Note: Male CC: Joshua presents with irritability, anger outbursts, and difficulty concentrating, particularly since his sibling has moved in with him and his grandmother. HPI: Joshua has a history of early childhood trauma, including neglect and abuse by his biological parents, and has been in the care of his grandmother since he was 18 months old, with a brief failed reunification attempt at age 5. His trauma history includes witnessing domestic violence and being physically abused. Joshua describes his mood as "angry most of the time," especially when he feels that his sister is receiving more attention. He states that these feelings have worsened over the past several months. He becomes easily angered and frustrated both at home and school, with frequent mood swings and explosive reactions. He has difficulty sleeping, feels constantly on edge, and struggles to concentrate in class. Joshua was just told he has ADHD and Oppositional Defiant Disorder (ODD), but he doesn't have an IEP yet. Joshua has been identified with ADHD and ODD in the past few months, but his school does not yet have an IEP in place for him. He has been having more and more trouble controlling his anger, especially since his brother moved in with him. During assessment: Joshua describes his mood as "angry most of the time," especially when he feels that his sister is receiving more attention. He indicated that this anger and irritability have worsened over the past several months, particularly after his sister moved in. Joshua reports frequent outbursts both at home and school, which interfere with his social and academic functioning. The patient's sense of self-worth seems normal, and they haven't reported feeling too guilty. No anhedonia was recorded. No major sleep problems, though he does say it's hard for him to fall asleep when he's mad. No change in hunger was recorded. No problems with libido were mentioned (age-appropriate). There have been no reports of changes in energy levels, focus, or memory that aren't linked to ADHD problems. The patient doesn't say that they are more active, agitated, acting risky, speaking quickly, or feeling happy. The patient doesn't say they have too many fears, worries, or panic attacks. The patient doesn't say that they have any dreams, illusions, urges, or compulsions. The patient's level of movement, focus, and attention were seen to change, and they had a lot of trouble in organized settings like school. Joshua is two years behind in reading but shows interest in Art. SI/HI/AV: At this point, the patient says they don't have suicidal thoughts (SI), hurt themselves (SIBx), want to kill someone (HI), act violently, or do anything else that is wrong or illegal. Allergies: No known drug or food allergies. Past Medical Hx: Medical: No history of chronic infections or major medical conditions. Psychiatric: Recently diagnosed with ODD and ADHD. No prior psychiatric hospitalizations. Substance Use: No substance use reported. Developmental History: Early childhood trauma due to parental neglect and abuse. Removed from parental care at 18 months old. Trauma History: Joshua was taken away from his parents because they neglected him, hurt him, and used drugs. Since he was 18 months old, his grandma has raised him. There was a short attempt to reunite them when he was 5, but it failed because of more abuse. His mother and father split up, and he doesn't talk to his father anymore. Little to no interaction with his mother at family events. Current Medications: None reported. Family Psychiatric History: Mother: Substance use and childhood trauma history. No psychiatric diagnoses reported in the immediate family. Social History: Joshua lives with his grandmother, who struggles with depression and difficulty managing his emotional outbursts. He is currently in the 6th grade, and his favorite class is art, while he dislikes remedial reading. His social interactions are good when in a positive mood, but volatile otherwise. Review of Systems (ROS):
|
|
Verify Patient: Name, Assigned identification number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo. Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview. HPI: , Past Medical and Psychiatric History, Current Medications, Previous Psych Med trials, Allergies. Social History, Family History. Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…” |
|
|
Objective |
Vital Signs: Stable
LABS:
Physical Exam: General Appearance: Joshua appears his stated age, dressed appropriately for his age and the season. He presents with good hygiene and grooming. No signs of acute distress noted. Vital Signs: Stable (as noted above in Objective section). Psychomotor Activity: Mild agitation was noted, especially when discussing his frustrations regarding his sibling and school, but no hyperactivity or lethargy observed. Behavior: Cooperative during the exam but reactive when discussing emotionally charged topics, such as feeling neglected in favor of his sister. Eye Contact: Maintains appropriate eye contact. Speech: Spontaneous, normal rate and volume, no slurring or rapid speech. Mood: Irritable, as self-reported. Affect: Constricted but shifts to volatile during emotionally charged topics. Thought Process: Coherent, goal-directed, no signs of disorganized thinking or tangential thoughts. Thought Content: No delusions, hallucinations, or paranoid thoughts elicited. Cognition: Grossly intact, with appropriate attention span and concentration considering his ADHD diagnosis. Insight and Judgment: Fair. Joshua shows awareness of his behaviors and mood but struggles to manage them. He acknowledges that he has difficulty controlling his anger but does not yet fully understand the impact of his actions on others. MSE: Appearance: Age-appropriate, clean, and casually dressed. Behavior: Cooperative but appeared easily frustrated. Mood: Irritable. Affect: Constricted but shifts to volatile. Speech: Normal in rate and volume. Thought Process: Goal-directed, coherent. Thought Content: No evidence of delusions or hallucinations. Insight and Judgment: Fair. Attention/Concentration: Impaired, particularly in structured settings. SI/HI: Denies suicidal ideation or homicidal ideation. Psychomotor Activity: Mildly agitated. Diagnostic testing: Conners' Rating Scales and Vanderbilt ADHD Diagnostic Parent and Teacher Rating Scales to assess ADHD symptoms and their severity. PHQ-9: Minimal signs of depression. Trauma Symptom Checklist for Children (TSCC) may be beneficial for further evaluation of trauma responses. |
|
This is where the “facts” are located. Vitals, **Physical Exam (if performed, will not be performed every visit in every setting) Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results. |
|
|
Assessment |
DSM5 Diagnosis: with ICD-10 codes Oppositional Defiant Disorder (ODD) - ICD-10 code: F91.3 Oppositional Defiant Disorder (ODD) is when someone is consistently angry or restless, acts defiantly or in an arguing way, and is mean for at least six months. This condition has a big effect on children and teens' social, educational, and professional performance. The signs usually show up when dealing with adults in charge, like parents or teachers. They include losing their cool a lot, being defiant, and not following the rules. Attention Deficit Hyperactivity Disorder (ADHD) often co-occurs with ODD, which makes it harder to treat and raises the risk of bad results like school problems and broken relationships (Hawes et al., 2023). Cognitive-behavioral treatment, parent management training, and programs meant to improve conversation and problem-solving skills are common ways to treat ODD. The long-term effects of the disorder can be lessened by diagnosing and treating it early on. Attention Deficit Hyperactivity Disorder (ADHD), combined presentation - ICD-10 code: F90.2 Individuals with Attention Deficit Hyperactivity Disorder (ADHD) often don't pay attention and are too busy or reckless, which gets in the way of their work or growth. There have been signs of both inattentional like not being able to concentrate and forgetting things and hyperactivity-impulsivity (like moving and talking too much) for at least six months in different places. It can be hard for children with both types of ADHD to do well in school, make friends, and keep their behavior in check. According to Retz et al (2021), up to 5% of children around the world have ADHD, making it one of the most common brain disorders in children. Most people who have this problem get help in the form of behavioral therapy, parent training, and drugs that help control symptoms, like stimulants like methylphenidate and non-stimulants. For children with ADHD to get better in the long run, they need to get help as soon as possible. Post-Traumatic Stress Disorder (PTSD) - Consider differential diagnosis based on trauma history - ICD-10 code: F43.10 PTSD is a mental illness that can happen to people who have been through or seen something upsetting, like abuse, violence, or neglect. Children with PTSD may re-experience the trauma for example, through flashbacks or dreams, avoid things that remind them of the trauma, have negative changes in their thinking and mood, and be more alert. Given Joshua’s history of neglect and physical abuse by his parents, PTSD should be considered as a differential diagnosis, particularly due to his frequent angry outbursts, mood swings, and sleep difficulties. According to Taylor et al (2021), PTSD in children can overlap with other conditions like ADHD and Oppositional Defiant Disorder, making it crucial to carefully assess and differentiate symptoms. Trauma-focused cognitive behavioral therapy (TF-CBT) is one of the most effective treatments for pediatric PTSD. |
|
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. Informed Consent Ability |
|
|
Plan |
Pharmacologic Interventions: Initiate Methylphenidate (Ritalin) 5mg once daily to manage ADHD symptoms, titrate weekly based on response and tolerance. Consider Guanfacine (0.5 mg/day) if oppositional behaviors remain problematic after ADHD symptom stabilization. Monitor for side effects, particularly sleep disturbances, appetite suppression, and mood changes. Non-Pharmacologic Interventions: Cognitive Behavioral Therapy (CBT) to address oppositional behaviors, emotion regulation, and trauma-related responses. Referral for Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) to process early childhood trauma. Behavioral interventions both at home and in school settings. Collaboration with school staff to implement an Individualized Education Plan (IEP) focusing on ADHD accommodations and emotional regulation strategies. Recommend Parent Management Training (PMT) for the grandmother to help manage Joshua's behavioral challenges and provide emotional support. Education and Health Promotion: Educate Joshua and his grandmother about ADHD and ODD. Discuss the importance of consistent routines, boundaries, and positive reinforcement to manage oppositional behaviors. Encourage a supportive sleep hygiene routine to address sleep disturbances. Safety Plan: Safety planning to address escalating anger outbursts, ensuring Joshua and his grandmother understand de-escalation techniques. Grandmother is encouraged to contact support services if behaviors become unmanageable at home or school. Follow-Up: Schedule a follow-up appointment in 2 weeks to monitor the efficacy of medication, assess behavioral improvements, and further engage in psychotherapy. Assess side effects and make any necessary changes to the drug treatment. Time spent in Psychotherapy: 20 minutes Total visit time: 60 minutes Billing Codes: XX for initial psychiatric evaluation XX for medication management XX for psychotherapy ____________________________________________ NAME Date: Time: |
|
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 and include patient education. |
References
Hawes, D. J., Gardner, F., Dadds, M. R., Frick, P. J., Kimonis, E. R., Burke, J. D., & Fairchild, G. (2023). Oppositional defiant disorder. Nature Reviews Disease Primers, 9(1), 31.
Retz, W., Ginsberg, Y., Turner, D., Barra, S., Retz-Junginger, P., Larsson, H., & Asherson, P. (2021). Attention-Deficit/Hyperactivity Disorder (ADHD), antisociality and delinquent behavior over the lifespan. Neuroscience & Biobehavioral Reviews, 120, 236-248.
Taylor Miller, P. G., Sinclair, M., Gillen, P., McCullough, J. E. M., Miller, P. W., Farrell, D. P., ... & Klaus, P. (2021). Early psychological interventions for prevention and treatment of post-traumatic stress disorder (PTSD) and post-traumatic stress symptoms in post-partum women: A systematic review and meta-analysis. PLoS One, 16(11), e0258170.
BEST SOAP NOTE WRITING SERVICE
Depression and Anxiety: Understanding the Connection and Treatment Approaches
Depression and anxiety are two of the most common mental health disorders globally, and they often co-occur. Although they are distinct conditions, they share many symptoms, such as irritability, difficulty concentrating, and sleep disturbances. The prevalence of both conditions has increased in recent years, particularly during the COVID-19 pandemic, as individuals faced unprecedented stressors, isolation, and uncertainty. Understanding the nuances of depression and anxiety, as well as the relationship between the two, is essential for effective diagnosis and treatment.
Understanding Depression
Depression, or Major Depressive Disorder (MDD), is a mood disorder characterized by persistent sadness, loss of interest in activities, and a range of emotional and physical symptoms that interfere with daily functioning. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), for a diagnosis of depression, an individual must experience at least five symptoms for two weeks or more. These symptoms include a depressed mood, diminished interest or pleasure in activities, significant weight loss or gain, insomnia or hypersomnia, fatigue, feelings of worthlessness, and recurrent thoughts of death or suicide (American Psychiatric Association, 2013).
The causes of depression are multifactorial, including biological, genetic, environmental, and psychological factors. Research has shown that imbalances in neurotransmitters such as serotonin, dopamine, and norepinephrine play a critical role in the development of depression. Additionally, genetic predispositions, coupled with environmental stressors such as trauma, loss, or chronic illness, increase the likelihood of developing the disorder (LeMoult & Gotlib, 2019).
Understanding Anxiety
Anxiety is a normal emotional response to stress, but when it becomes chronic and overwhelming, it can develop into an anxiety disorder. Generalized Anxiety Disorder (GAD) is one of the most common forms of anxiety, characterized by excessive worry about various aspects of daily life. Symptoms include restlessness, difficulty concentrating, muscle tension, fatigue, and sleep disturbances. Other anxiety disorders include panic disorder, social anxiety disorder, and specific phobias.
The physiological mechanisms of anxiety involve the activation of the body's fight-or-flight response, which is controlled by the amygdala and other brain regions involved in fear processing. When anxiety becomes chronic, this response is triggered inappropriately, leading to a state of hyperarousal and constant worry. Like depression, anxiety disorders are influenced by both genetic predispositions and environmental factors. Studies have demonstrated a strong genetic correlation, with heritability estimates for anxiety disorders ranging from 30% to 50% (Bandelow et al., 2017).
The Connection Between Depression and Anxiety
Depression and anxiety frequently co-occur, with studies indicating that more than 60% of individuals diagnosed with depression also experience symptoms of anxiety (Kessler et al., 2015). This comorbidity can complicate diagnosis and treatment, as the symptoms of one disorder can exacerbate the other. For example, the constant worry and hyperarousal associated with anxiety can lead to feelings of hopelessness and despair, common in depression. Conversely, individuals with depression may experience heightened anxiety due to concerns about their inability to function or recover from their condition.
The co-occurrence of depression and anxiety is thought to result from shared genetic and neurobiological mechanisms. Both disorders are associated with dysregulation in the hypothalamic-pituitary-adrenal (HPA) axis, which controls the body's stress response. Additionally, abnormalities in the serotonin and norepinephrine systems contribute to both conditions. Cognitive patterns such as rumination, where individuals obsess over negative thoughts, are also common in both depression and anxiety and can exacerbate the severity of each disorder (Harvey et al., 2014).
Treatment Approaches for Depression and Anxiety
Treating depression and anxiety, particularly when they co-occur, requires a multifaceted approach. Both pharmacological and psychotherapeutic interventions are effective, and treatment plans are often individualized based on the severity of symptoms and patient preferences.
- Pharmacological Treatments: Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine and sertraline, are commonly prescribed for both depression and anxiety. SSRIs increase the availability of serotonin in the brain, helping to regulate mood and reduce symptoms of both disorders. Serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine, are also effective in treating both conditions. For individuals with severe anxiety, benzodiazepines may be used short-term, although they are typically avoided due to the risk of dependence (Craske et al., 2017).
- Psychotherapy: Cognitive-behavioral therapy (CBT) is one of the most effective forms of psychotherapy for treating both depression and anxiety. CBT helps individuals identify and challenge negative thought patterns, develop coping strategies, and practice relaxation techniques. Another psychotherapeutic approach is mindfulness-based therapy, which teaches individuals to focus on the present moment and reduce the rumination that exacerbates both anxiety and depression (Hofmann et al., 2012).
- Lifestyle Interventions: Lifestyle modifications, such as regular exercise, a healthy diet, and adequate sleep, can significantly improve symptoms of depression and anxiety. Physical activity, in particular, has been shown to reduce symptoms of both disorders by releasing endorphins and improving overall well-being. Mind-body practices such as yoga and meditation can also help individuals manage stress and regulate their emotions more effectively (Carek et al., 2011).
- Combined Treatment Approaches: For individuals with both depression and anxiety, a combination of medication and psychotherapy is often the most effective treatment approach. Studies have shown that this combined treatment is more effective than either approach alone, particularly for individuals with moderate to severe symptoms (Cuijpers et al., 2014).
Conclusion
Depression and anxiety are prevalent, often co-occurring mental health disorders that significantly impact an individual's quality of life. Understanding the connection between these two conditions and implementing a comprehensive treatment plan can help improve outcomes. A combination of pharmacotherapy, psychotherapy, and lifestyle interventions is typically the most effective approach, providing individuals with the tools to manage their symptoms and improve their overall well-being.
References:
