SOAP Note 1
Maria Socorro A Romea
Wilkes University
NSG 535-IKQ: Advanced Practice in Psychiatric Mental Health
Nursing I
Dr. Ileana Asanache
Date:
This study source was downloaded by 100000878946013 from CourseHero.com on 09-18-2024 13:31:50 GMT -05:00
https://www.coursehero.com/file/234723498/SOAP-note-templatedocx/
, SOAP NOTE for a follow up visit
Patient Name:
Date of Birth:
Date of Service:
Chief Complaint:
Subjective:
The patient, Mr. A, a 35-year-old male, presents today with complaints of persistent sadness, low
mood, and loss of interest in previously enjoyable activities. He reports feeling down most of the
time and having difficulty sleeping and concentrating. Mr. A states that these symptoms have
been present for the past six months and have significantly impacted his daily functioning. He
denies any history of suicidal ideation or intent but acknowledges a sense of hopelessness and
worthlessness. He mentions increased irritability and decreased appetite. Mr. A reports no
significant stressors or recent life changes contributing to his current condition.
Assess the symptoms of the disease that are sufficiently descriptive (old carts) to validate
Dx per DSM-5 criteria. Include pertinent negatives even for follow-ups.
Include current psychiatric medications and response to treatment. Specify de directions
of each medication from the med list such us PO/IM/SQ, daily, BID, TID, AM or PM and
what it is ordered for (depression, anxiety, ADHD, insomnia, psychosis).
The list of medication(s)s should include the dose, route, and frequency along with the
medication’s name.
Assess sleep, appetite, and self-care at each visit.
Use the acronyms SIGECAPS to assess for symptoms of depression and AND I C REST
for symptoms of anxiety.
DIG FAST mnemonic can be a great tool to assess the signs and symptoms of bipolar.
Objective:
During the assessment, Mr. A appeared sad and had a restricted range of affect. He displayed
psychomotor retardation and slowed speech. His hygiene and grooming were poor, with
disheveled hair and unkempt clothing. His eye contact was minimal throughout the session. Mr.
A's mood was consistently depressed, with occasional tearfulness. He reported feeling fatigued
and had a decreased appetite, resulting in noticeable weight loss. There were no signs of
psychosis or cognitive impairment. The patient's vital signs and general physical examination
were within normal limits.
Mental Status Exam must be in a narrative form including all elements and be as
descriptive as possible in describing the patient’s presentation.
This study source was downloaded by 100000878946013 from CourseHero.com on 09-18-2024 13:31:50 GMT -05:00
https://www.coursehero.com/file/234723498/SOAP-note-templatedocx/
Maria Socorro A Romea
Wilkes University
NSG 535-IKQ: Advanced Practice in Psychiatric Mental Health
Nursing I
Dr. Ileana Asanache
Date:
This study source was downloaded by 100000878946013 from CourseHero.com on 09-18-2024 13:31:50 GMT -05:00
https://www.coursehero.com/file/234723498/SOAP-note-templatedocx/
, SOAP NOTE for a follow up visit
Patient Name:
Date of Birth:
Date of Service:
Chief Complaint:
Subjective:
The patient, Mr. A, a 35-year-old male, presents today with complaints of persistent sadness, low
mood, and loss of interest in previously enjoyable activities. He reports feeling down most of the
time and having difficulty sleeping and concentrating. Mr. A states that these symptoms have
been present for the past six months and have significantly impacted his daily functioning. He
denies any history of suicidal ideation or intent but acknowledges a sense of hopelessness and
worthlessness. He mentions increased irritability and decreased appetite. Mr. A reports no
significant stressors or recent life changes contributing to his current condition.
Assess the symptoms of the disease that are sufficiently descriptive (old carts) to validate
Dx per DSM-5 criteria. Include pertinent negatives even for follow-ups.
Include current psychiatric medications and response to treatment. Specify de directions
of each medication from the med list such us PO/IM/SQ, daily, BID, TID, AM or PM and
what it is ordered for (depression, anxiety, ADHD, insomnia, psychosis).
The list of medication(s)s should include the dose, route, and frequency along with the
medication’s name.
Assess sleep, appetite, and self-care at each visit.
Use the acronyms SIGECAPS to assess for symptoms of depression and AND I C REST
for symptoms of anxiety.
DIG FAST mnemonic can be a great tool to assess the signs and symptoms of bipolar.
Objective:
During the assessment, Mr. A appeared sad and had a restricted range of affect. He displayed
psychomotor retardation and slowed speech. His hygiene and grooming were poor, with
disheveled hair and unkempt clothing. His eye contact was minimal throughout the session. Mr.
A's mood was consistently depressed, with occasional tearfulness. He reported feeling fatigued
and had a decreased appetite, resulting in noticeable weight loss. There were no signs of
psychosis or cognitive impairment. The patient's vital signs and general physical examination
were within normal limits.
Mental Status Exam must be in a narrative form including all elements and be as
descriptive as possible in describing the patient’s presentation.
This study source was downloaded by 100000878946013 from CourseHero.com on 09-18-2024 13:31:50 GMT -05:00
https://www.coursehero.com/file/234723498/SOAP-note-templatedocx/
