Comprehensive Psychiatric SOAP Note
Client ID (age, marital status, race, gender) 30-yr-old divorced Caucasian female.
Subjective: (Include reason for visit, interval problems since last visit, medication-related,
include all relevant pertinent positive and negatives, include symptoms that support the
patient’s chief complaint(s))
Chief complaint: (In patient’s words in quotations, patient treatment expectations and reason
for visit) Here for follow up and medication management. Client reports, ”I really like the
Lexapro. It has helped me a lot.”
Source of reliability: Reliability of information is good. Presents alone.
Present illness: (HPI symptoms including pertinent negatives and positives, pertinent parts of
the PMH, FH, SH, habits, etc., include current medication and non-pharmacological treatment
regimens along with drug allergies, include comorbid conditions, interval problems since last
visit, medication related issues)
Client reports that current medication regime is working well. She has been on Lexapro for about
4 weeks now related to stresses of a being a single mom to 2 children. One is going to
kindergarten this year. Sleeps 7-8 hours at night and Lexapro has improved quality of sleep. No
current SI/HI/SA/SIB/AVH expressed during visit. No delusional or OCD thoughts. Denies
feeling hopeless, helpless or worthlessness. Denies feeling sad. Motivation and energy are fair
and is able to do all daily tasks at work and home. Reports occ anxiety and worrying about her
children.
Current psych meds: (effectiveness, reported side effects): Lexapro 10mg po qd, tolerating well
and reports effective.
Past psychiatric history: (medications, hospitalizations, previous outpatient treatment, SAs,
previous dx): No inpatient hospitalizations and no previous psych care or medications.
Past medical history: (major illness, hospitalizations) Allergies: none. Denies seizures, cardiac
arrythmias or head injuries or congenital heart defects. 2 C-sections.
Substance use/abuse: No tobacco, ETOH or x of illegal drug use. Caffeine: 2-3 cokes daily.
Past family, social history (include developmental history for adolescents, military, legal,
trauma, abuse/violence in home, family psychiatric history)
Family psych hx: Maternal side: depression. No hx of physical, emotional and sexual abuse.
Lived with mother growing up and 2 siblings. Parents divorced when she was 6 but has good
relationship with father. Born and raised in Pittsburgh.
Education/Employment/Disability: Has a HS diploma and works as a receptionist.
Primary support system: Mom, dad, stepmom, siblings and grandparents.
Hobbies: movies and “chasing down kids”
Review of systems-pertinent (per GM):
Client ID (age, marital status, race, gender) 30-yr-old divorced Caucasian female.
Subjective: (Include reason for visit, interval problems since last visit, medication-related,
include all relevant pertinent positive and negatives, include symptoms that support the
patient’s chief complaint(s))
Chief complaint: (In patient’s words in quotations, patient treatment expectations and reason
for visit) Here for follow up and medication management. Client reports, ”I really like the
Lexapro. It has helped me a lot.”
Source of reliability: Reliability of information is good. Presents alone.
Present illness: (HPI symptoms including pertinent negatives and positives, pertinent parts of
the PMH, FH, SH, habits, etc., include current medication and non-pharmacological treatment
regimens along with drug allergies, include comorbid conditions, interval problems since last
visit, medication related issues)
Client reports that current medication regime is working well. She has been on Lexapro for about
4 weeks now related to stresses of a being a single mom to 2 children. One is going to
kindergarten this year. Sleeps 7-8 hours at night and Lexapro has improved quality of sleep. No
current SI/HI/SA/SIB/AVH expressed during visit. No delusional or OCD thoughts. Denies
feeling hopeless, helpless or worthlessness. Denies feeling sad. Motivation and energy are fair
and is able to do all daily tasks at work and home. Reports occ anxiety and worrying about her
children.
Current psych meds: (effectiveness, reported side effects): Lexapro 10mg po qd, tolerating well
and reports effective.
Past psychiatric history: (medications, hospitalizations, previous outpatient treatment, SAs,
previous dx): No inpatient hospitalizations and no previous psych care or medications.
Past medical history: (major illness, hospitalizations) Allergies: none. Denies seizures, cardiac
arrythmias or head injuries or congenital heart defects. 2 C-sections.
Substance use/abuse: No tobacco, ETOH or x of illegal drug use. Caffeine: 2-3 cokes daily.
Past family, social history (include developmental history for adolescents, military, legal,
trauma, abuse/violence in home, family psychiatric history)
Family psych hx: Maternal side: depression. No hx of physical, emotional and sexual abuse.
Lived with mother growing up and 2 siblings. Parents divorced when she was 6 but has good
relationship with father. Born and raised in Pittsburgh.
Education/Employment/Disability: Has a HS diploma and works as a receptionist.
Primary support system: Mom, dad, stepmom, siblings and grandparents.
Hobbies: movies and “chasing down kids”
Review of systems-pertinent (per GM):
