Psych soap note | Nursing homework help

 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?

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