Initial Psychiatric Interview/SOAP Note Template
Criteria Clinical Notes
Informed Consent Parents are legal guardian of patient due to autism spectrum
Subjective Patient
Verify Patient: Name, Name: Jane D.
Assigned identification DOB: 06/01/1988
number (e.g., medical
record number), Date of
birth, Phone number, Minor: No
Social security number, Accompanied by: mother and father
Address, Photo.
Demographic: Caucasian
Include
demographics, chief CC: “I want my Clozaril increased, I’m not sleeping”
complaint, subjective
information from the HPI:
patient, names and
relations of others Pertinent history in record and from patient: patient endorse she has been feeling weird,
present in the unable to fully express self-due to limitation in finding words to articulate self, parents states
interview. her mood has been “off” for a while and she recently fell in the living room, sustain a fracture
toe and hairline fracture on her coccyx. Patient identified she has been taken 450mg of Clozaril
HPI: , Past Medical instead of 125mg bid daily. Reported that what’s “indicated on the bottle”
and Psychiatric
During assessment: patient appears to be sitting on the edge of the chair, holding her cutches,
History, bilateral, with a stoop posture and looking downward with poor eye contact. Presented with
Current Medications, some stutter as she form her words. Mood appears to be congruent for her states age appears
Previous Psych Med to have some spectrum and delayed in thought process. Patient also indicated she is not sleep
trials, she would like an increase in her sleeping medication. Patient reports she is not sleeping well
Allergies. at night would watch television until 2am in the mornings, while parents are asleep, reports
medication is not affective.
Social History,
Family History. Patient currently endorse increased activity, agitation, pressured speech,. Patient does not
Review of Systems report excessive fears, worries or panic attacks. Patient endorses some hallucinations at night,
(ROS) – if ROS is reported seeing flashing lights when trying to sleep. Denies any delusions, obsessions, or
negative, “ROS compulsions. Patient’s activity level, attention and concentration were observed to be
noncontributory,” or diminished.
“ROS negative with
SI/ HI/ AV: Denies
the exception of…”
Allergies: PCN
(medication & food)
, Past Medical Hx: “ DM Type, obesity
Past Psychiatric Hx: BA inpatient for 2 weeks due to aggression Jan 2021
Previous psychiatric diagnoses: Schizoaffective disorder bipolar type & Autism spectrum
Describes stable course of illness: unstable at this time.
Previous medication trials: none reported.
Safety concerns: Falls and seizures precaution
Trauma history: Aggression
Substance Use: none reported
Current Medications: Clozaril, Metformin, Ambien, Metropolol, Ibuprofen and Novolog
Past Psych Med Trials: none reported.
Family Medical Hx: Mother DM type 1 and Father HTN
Family Psychiatric Hx: Mother anxiety, father depression
Social History:
Alcohol: denies drinking alcohol
Tobacco: No
Illicit Drugs: No
Exercise: patient does not exercise, has a sanitary lifestyle, morbidly obese with BMI of 43.8
Diet: 1800 ADA- does not follow
Occupational History: no employment
Military service History: none reported
Education history: some home schooling
Developmental History: some retardation
Legal History: none reported
Spiritual/Cultural Considerations: none reported.
ROS: Not assessed
Objective Vital Signs:
This is where the Height: 5’5” Weight: 263lb BMI:43.8 BP:169/85mmHg T:98 F P:78 bpm RR:18 bpm O2:99%
“facts” are Pain:0/10
located. Vitals,
**Physical Exam (if LABS: CBC
performed, will not be
performed every visit Physical Exam: Not assessed
in every setting)
Include relevant labs, MSE:
test results, and Patient is present with his legal guardian mother and father, patient, disheveled looking, hair
Include MSE, risk not combed, overweight, easily distracted with normal arousal and alertness, speech at times is
assessment here, and a bit slurred, loud then rapid, able to comprehend and express self with some delays in forming
thoughts. Patient has persistent sweat of bead on her forehead, at times would look at parents
Criteria Clinical Notes
Informed Consent Parents are legal guardian of patient due to autism spectrum
Subjective Patient
Verify Patient: Name, Name: Jane D.
Assigned identification DOB: 06/01/1988
number (e.g., medical
record number), Date of
birth, Phone number, Minor: No
Social security number, Accompanied by: mother and father
Address, Photo.
Demographic: Caucasian
Include
demographics, chief CC: “I want my Clozaril increased, I’m not sleeping”
complaint, subjective
information from the HPI:
patient, names and
relations of others Pertinent history in record and from patient: patient endorse she has been feeling weird,
present in the unable to fully express self-due to limitation in finding words to articulate self, parents states
interview. her mood has been “off” for a while and she recently fell in the living room, sustain a fracture
toe and hairline fracture on her coccyx. Patient identified she has been taken 450mg of Clozaril
HPI: , Past Medical instead of 125mg bid daily. Reported that what’s “indicated on the bottle”
and Psychiatric
During assessment: patient appears to be sitting on the edge of the chair, holding her cutches,
History, bilateral, with a stoop posture and looking downward with poor eye contact. Presented with
Current Medications, some stutter as she form her words. Mood appears to be congruent for her states age appears
Previous Psych Med to have some spectrum and delayed in thought process. Patient also indicated she is not sleep
trials, she would like an increase in her sleeping medication. Patient reports she is not sleeping well
Allergies. at night would watch television until 2am in the mornings, while parents are asleep, reports
medication is not affective.
Social History,
Family History. Patient currently endorse increased activity, agitation, pressured speech,. Patient does not
Review of Systems report excessive fears, worries or panic attacks. Patient endorses some hallucinations at night,
(ROS) – if ROS is reported seeing flashing lights when trying to sleep. Denies any delusions, obsessions, or
negative, “ROS compulsions. Patient’s activity level, attention and concentration were observed to be
noncontributory,” or diminished.
“ROS negative with
SI/ HI/ AV: Denies
the exception of…”
Allergies: PCN
(medication & food)
, Past Medical Hx: “ DM Type, obesity
Past Psychiatric Hx: BA inpatient for 2 weeks due to aggression Jan 2021
Previous psychiatric diagnoses: Schizoaffective disorder bipolar type & Autism spectrum
Describes stable course of illness: unstable at this time.
Previous medication trials: none reported.
Safety concerns: Falls and seizures precaution
Trauma history: Aggression
Substance Use: none reported
Current Medications: Clozaril, Metformin, Ambien, Metropolol, Ibuprofen and Novolog
Past Psych Med Trials: none reported.
Family Medical Hx: Mother DM type 1 and Father HTN
Family Psychiatric Hx: Mother anxiety, father depression
Social History:
Alcohol: denies drinking alcohol
Tobacco: No
Illicit Drugs: No
Exercise: patient does not exercise, has a sanitary lifestyle, morbidly obese with BMI of 43.8
Diet: 1800 ADA- does not follow
Occupational History: no employment
Military service History: none reported
Education history: some home schooling
Developmental History: some retardation
Legal History: none reported
Spiritual/Cultural Considerations: none reported.
ROS: Not assessed
Objective Vital Signs:
This is where the Height: 5’5” Weight: 263lb BMI:43.8 BP:169/85mmHg T:98 F P:78 bpm RR:18 bpm O2:99%
“facts” are Pain:0/10
located. Vitals,
**Physical Exam (if LABS: CBC
performed, will not be
performed every visit Physical Exam: Not assessed
in every setting)
Include relevant labs, MSE:
test results, and Patient is present with his legal guardian mother and father, patient, disheveled looking, hair
Include MSE, risk not combed, overweight, easily distracted with normal arousal and alertness, speech at times is
assessment here, and a bit slurred, loud then rapid, able to comprehend and express self with some delays in forming
thoughts. Patient has persistent sweat of bead on her forehead, at times would look at parents
