S.O.A.P. Note Template CASE ID# Tina Jones- Mental Health
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S.O.A.P. Note TemplatCASE ID# Tina Jones- Mental Health
Subjectiv
e
Objective
Assessment (diagnosis [primary and differential diagnosis])
Plan (treatment, education, and follow up plan)
mplaintChief
What brought you Difficulty sleeping
here today…
(eg. headache)
Chronological order of events, state of health before onset of CC, must include OLDCARTS in paragraph form
Onset Ms. Jones presents to the clinic complaining of difficulty sleeping which she notes to have
Location started 1 month ago. She states that her sleep is “shallow and not restful”. She complains of
History of
Duration difficulty falling asleep at least 4 or 5 nights per week, but states that she is able to stay asleep
Present
Character without difficulty. On average she sleeps 4 or 5 hours per night and awakens at 8:00am daily.
Illness
Aggravating/associated She states that she has a fairly consistent schedule on weekdays and weekends. She does not
factors take any prescription or over the counter sleep aids. She limits screen time prior to bed and
Relieving does not ingest caffeine after 4pm daily. She endorses decreased feelings of sleepiness over
factors
the past month. She denies difficulties awaking but does not feel rested in the morning and has
Temporal factors –
daytime fatigue (rates 5/10 severity), restlessness, and irritability (rates 2/10 severity). She
other
things going on does not take naps.
Severity
Adult Illnesses, Childhood asthma, diagnosed when she was 2.5 years old, last hospitalization when she was
childhood 16 years old, uses Proventil inhaler 2 puffs q 4 hours PRN. Also has type 2 diabetes,
Medical
History
diagnosed when she was 24 years old, managed by diet.
illnesses,
Past
immunizations,
surgeries,
allergies, current
medications
Include
Parents, Denies any history of known sleep disorders or psychiatric disorders.
siblings;
History
Family
grandparents if
applicable/kno
wn, cause of
death,
Education, She states that she has some stress related to her upcoming examinations and her impending
job search upon graduation. She states that she has a strong support system made up of
marital status,
friends and family and she is active in her church. She states that she copes with stress by
occupation, staying organized. She enjoys reading and watching television (1-2 hours per day). She states
alcohol/drug use, that her father died in a car accident a year and a half ago, which was difficult for her and she
Personal/Social
smoking status, experienced some difficulties with sleep at that time as well. She denies use of tobacco. She
drinks approximately 10-12 alcoholic beverages per month, but never more than 3 per sitting
sexual history if and does not note any impact on her sleep. She has used marijuana in the past, but no current
History
relevant, use and denies other illicit drugs. She does not exercise regularly, but states that her job is
exercise, somewhat active, and she walks 5-15 minutes daily. She drinks 1-3 diet colas per day.
nutrition,
religious
preference if
known
R
e
v
Denies changes in weight, weakness, fever, chills, and night sweats. Does complain of
General:
increasing daytime
fatigue.
Hair, Skin, & n/a
Nails:
Head: n/a
https://www.coursehero.com/file/76123647/SOAP-5-Mental-Healthdocx/
\
S.O.A.P. Note TemplatCASE ID# Tina Jones- Mental Health
Subjectiv
e
Objective
Assessment (diagnosis [primary and differential diagnosis])
Plan (treatment, education, and follow up plan)
mplaintChief
What brought you Difficulty sleeping
here today…
(eg. headache)
Chronological order of events, state of health before onset of CC, must include OLDCARTS in paragraph form
Onset Ms. Jones presents to the clinic complaining of difficulty sleeping which she notes to have
Location started 1 month ago. She states that her sleep is “shallow and not restful”. She complains of
History of
Duration difficulty falling asleep at least 4 or 5 nights per week, but states that she is able to stay asleep
Present
Character without difficulty. On average she sleeps 4 or 5 hours per night and awakens at 8:00am daily.
Illness
Aggravating/associated She states that she has a fairly consistent schedule on weekdays and weekends. She does not
factors take any prescription or over the counter sleep aids. She limits screen time prior to bed and
Relieving does not ingest caffeine after 4pm daily. She endorses decreased feelings of sleepiness over
factors
the past month. She denies difficulties awaking but does not feel rested in the morning and has
Temporal factors –
daytime fatigue (rates 5/10 severity), restlessness, and irritability (rates 2/10 severity). She
other
things going on does not take naps.
Severity
Adult Illnesses, Childhood asthma, diagnosed when she was 2.5 years old, last hospitalization when she was
childhood 16 years old, uses Proventil inhaler 2 puffs q 4 hours PRN. Also has type 2 diabetes,
Medical
History
diagnosed when she was 24 years old, managed by diet.
illnesses,
Past
immunizations,
surgeries,
allergies, current
medications
Include
Parents, Denies any history of known sleep disorders or psychiatric disorders.
siblings;
History
Family
grandparents if
applicable/kno
wn, cause of
death,
Education, She states that she has some stress related to her upcoming examinations and her impending
job search upon graduation. She states that she has a strong support system made up of
marital status,
friends and family and she is active in her church. She states that she copes with stress by
occupation, staying organized. She enjoys reading and watching television (1-2 hours per day). She states
alcohol/drug use, that her father died in a car accident a year and a half ago, which was difficult for her and she
Personal/Social
smoking status, experienced some difficulties with sleep at that time as well. She denies use of tobacco. She
drinks approximately 10-12 alcoholic beverages per month, but never more than 3 per sitting
sexual history if and does not note any impact on her sleep. She has used marijuana in the past, but no current
History
relevant, use and denies other illicit drugs. She does not exercise regularly, but states that her job is
exercise, somewhat active, and she walks 5-15 minutes daily. She drinks 1-3 diet colas per day.
nutrition,
religious
preference if
known
R
e
v
Denies changes in weight, weakness, fever, chills, and night sweats. Does complain of
General:
increasing daytime
fatigue.
Hair, Skin, & n/a
Nails:
Head: n/a
https://www.coursehero.com/file/76123647/SOAP-5-Mental-Healthdocx/
