NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation
Exemplar
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ
CAREFULLY
If you are struggling with the format or remembering what to include, follow the Focused
SOAP Note Evaluation Template AND the Rubric as your guide. It is also helpful to
review the rubric in detail in order not to lose points unnecessarily because you missed
something required. After reviewing full details of the rubric, you can use it as a guide.
In the Subjective section, provide:
• Chief complaint
• History of present illness (HPI)
• Past psychiatric history
• Medication trials and current medications
• Psychotherapy or previous psychiatric diagnosis
• Pertinent substance use, family psychiatric/substance use, social, and
medical history
• Allergies
• ROS
Read rating descriptions to see the grading standards!
In the Objective section, provide:
• Physical exam documentation of systems pertinent to the chief complaint,
HPI, and history
• Diagnostic results, including any labs, imaging, or other assessments needed
to develop the differential diagnoses.
Read rating descriptions to see the grading standards!
In the Assessment section, provide:
• Results of the mental status examination, presented in paragraph form.
• At least three differentials with supporting evidence. List them from top priority
to least priority. Compare the DSM-5-TR diagnostic criteria for each
differential diagnosis and explain what DSM-5-TR criteria rules out the
differential diagnosis to find an accurate diagnosis. Explain the critical-
thinking process that led you to the primary diagnosis you selected. Include
pertinent positives and pertinent negatives for the specific patient case.
• Read rating descriptions to see the grading standards!
Reflect on this case. Include: Discuss what you learned and what you might do
differently. Also include in your reflection a discussion related to legal/ethical
considerations (demonstrate critical thinking beyond confidentiality and consent
© 2022 Walden University Page 1 of 6
, NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation
Exemplar
for treatment!), social determinates of health, health promotion and disease prevention
taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and
other risk factors (e.g., socioeconomic, cultural background, etc.).
(The FOCUSED SOAP psychiatric evaluation is typically the follow-up visit patient note.
You will practice writing this type of note in this course. You will be focusing more on the
symptoms from your differential diagnosis from the comprehensive psychiatric
evaluation narrowing to your diagnostic impression. You will write up what symptoms
are present and what symptoms are not present from illnesses to demonstrate you have
indeed assessed for illnesses which could be impacting your patient. For example,
anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms,
substance use, etc.)
EXEMPLAR BEGINS HERE
Subjective:
CC (chief complaint): A brief statement identifying why the patient is here. This
statement is verbatim of the patient’s own words about why presenting for assessment.
For a patient with dementia or other cognitive deficits, this statement can be obtained
from a family member.
HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation,
current medication and referral reason. For example:
N.M. is a 34-year-old Asian male presents for medication management follow up for
anxiety. He was initiated sertraline last appt which he finds was effective for two weeks
then symptoms began to return.
Or
P.H., a 16-year-old Hispanic female, presents for follow up to discuss previous
psychiatric evaluation for concentration difficulty. She is not currently prescribed
psychotropic medications as we deferred until further testing and screening was
conducted.
Then, this section continues with the symptom analysis for your note. Thorough
documentation in this section is essential for patient care, coding, and billing analysis.
Paint a picture of what is wrong with the patient. First what is bringing the patient to your
follow up evaluation? Document symptom onset, duration, frequency, severity, and
impact. What has worsened or improved since last appointment? What stressors are
they facing? Your description here will guide your differential diagnoses into your
© 2022 Walden University Page 2 of 6
Exemplar
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ
CAREFULLY
If you are struggling with the format or remembering what to include, follow the Focused
SOAP Note Evaluation Template AND the Rubric as your guide. It is also helpful to
review the rubric in detail in order not to lose points unnecessarily because you missed
something required. After reviewing full details of the rubric, you can use it as a guide.
In the Subjective section, provide:
• Chief complaint
• History of present illness (HPI)
• Past psychiatric history
• Medication trials and current medications
• Psychotherapy or previous psychiatric diagnosis
• Pertinent substance use, family psychiatric/substance use, social, and
medical history
• Allergies
• ROS
Read rating descriptions to see the grading standards!
In the Objective section, provide:
• Physical exam documentation of systems pertinent to the chief complaint,
HPI, and history
• Diagnostic results, including any labs, imaging, or other assessments needed
to develop the differential diagnoses.
Read rating descriptions to see the grading standards!
In the Assessment section, provide:
• Results of the mental status examination, presented in paragraph form.
• At least three differentials with supporting evidence. List them from top priority
to least priority. Compare the DSM-5-TR diagnostic criteria for each
differential diagnosis and explain what DSM-5-TR criteria rules out the
differential diagnosis to find an accurate diagnosis. Explain the critical-
thinking process that led you to the primary diagnosis you selected. Include
pertinent positives and pertinent negatives for the specific patient case.
• Read rating descriptions to see the grading standards!
Reflect on this case. Include: Discuss what you learned and what you might do
differently. Also include in your reflection a discussion related to legal/ethical
considerations (demonstrate critical thinking beyond confidentiality and consent
© 2022 Walden University Page 1 of 6
, NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation
Exemplar
for treatment!), social determinates of health, health promotion and disease prevention
taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and
other risk factors (e.g., socioeconomic, cultural background, etc.).
(The FOCUSED SOAP psychiatric evaluation is typically the follow-up visit patient note.
You will practice writing this type of note in this course. You will be focusing more on the
symptoms from your differential diagnosis from the comprehensive psychiatric
evaluation narrowing to your diagnostic impression. You will write up what symptoms
are present and what symptoms are not present from illnesses to demonstrate you have
indeed assessed for illnesses which could be impacting your patient. For example,
anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms,
substance use, etc.)
EXEMPLAR BEGINS HERE
Subjective:
CC (chief complaint): A brief statement identifying why the patient is here. This
statement is verbatim of the patient’s own words about why presenting for assessment.
For a patient with dementia or other cognitive deficits, this statement can be obtained
from a family member.
HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation,
current medication and referral reason. For example:
N.M. is a 34-year-old Asian male presents for medication management follow up for
anxiety. He was initiated sertraline last appt which he finds was effective for two weeks
then symptoms began to return.
Or
P.H., a 16-year-old Hispanic female, presents for follow up to discuss previous
psychiatric evaluation for concentration difficulty. She is not currently prescribed
psychotropic medications as we deferred until further testing and screening was
conducted.
Then, this section continues with the symptom analysis for your note. Thorough
documentation in this section is essential for patient care, coding, and billing analysis.
Paint a picture of what is wrong with the patient. First what is bringing the patient to your
follow up evaluation? Document symptom onset, duration, frequency, severity, and
impact. What has worsened or improved since last appointment? What stressors are
they facing? Your description here will guide your differential diagnoses into your
© 2022 Walden University Page 2 of 6
