Psych SOAP NOTE
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.
TEMPLATE/ESSENTIAL ELEMENTS- WRITTEN FORMAT:
OSCE SOAP (Psych)NOTE
REQUIRED ELEMENTS OF THE SOAP (psych)NOTE
Student Name: ________________________________________Patient Initial____________
Patient Information
???? Gender
???? Height and Weight
???? Marital status
???? Occupation
???? Current medication
???? Past Psychiatric medication
???? Allergies
Subjective:
???? 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)
Objective
???? 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?