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ELISA HENDERICK I-HUMAN CASE- PSYCHIATRIC SOAP NOTE TEMPLATE 2024
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ELISA HENDERICK I-HUMAN CASE- PSYCHIATRIC SOAP NOTE TEMPLATE 2024
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ELISA HENDERICK I-HUMAN CASE-PSYCHIATRIC SOAP NOTE TEMPLATE
2024
Psychiatric SOAP Note Template
There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective,
Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to
develop your style of SOAP in the psychiatric practice setting. Refer to the Psychiatric SOAP
Note PowerPoint for further detail about each of these sections.
Criteria Clinical Notes
Subjective Patient presents complaining of weight loss, fatigue and loss of
Include chief interest in activities. 16 year-old female with reported hx of social
complaint, subjective anxiety and phobia, mainly related to her weight, has never been
information from the formally diagnosed/treated for these conditions. Patient reports that
patient, names and she feels overweight and has significantly reduced her caloric intake
relations of others because of this. Patient reports utilizing laxatives, and inducing
present in the vomiting voluntarily. Patient reports excessive exercise. Patient
interview, and basic reports recently experiencing amenorrhea and fracturing her left foot,
demographic required to wear a walking boot for 8 weeks. Patient reports the only
information of the medications she takes are over the counter laxatives. No known
patient. HPI, Past allergies. Reports that parents are divorced and that she lives with
Medical and mom, noting that mom is the reason she came in to be seen.
Psychiatric History,
Social History.
Objective Review of Systems
This is where the Constitutional- Recent weight loss reported. Denies fever, chills or
“facts” are located. night sweats.
Include relevant labs, HEENT- Denies changes in vision, hearing loss, difficulty
test results, vitals, and swallowing.
Review of Systems Cardiovascular- Patient reports experiencing 1 episode of fainting.
(ROS) – if ROS is Denies chest pain, arrhythmia, palpitations, SOB.
negative, “ROS Respiratory- Denies cough, SOB or wheezing.
noncontributory,” or Gastrointestinal- Patient reports inducing vomiting voluntarily and
“ROS negative with experiencing constipation. Denies abdominal pain, diarrhea, heart
the exception of…” burn or blood in stools.
Include MSE, risk Muscoloskeletal- Recent foot fracture. Otherwise denies joint
assessment here, and pain/swelling or restricted mobility.
psychiatric screening Neurological- Reports 1 recent episode of fainting. Denies
measure results. numbness/tingling, loss of sensation or burning.
Genitourinary- Denies frequent urination or urgency.
Endocrine- Denies intolerance to heat or cold, denies excessive
thirst.
Hematologic/Lymphatic- Reports amenorrhea.
Objective
, HR- 50
BP- 108/70 when supine, 80/50 standing
RR- 18
SpO2- 99% room air
Temp- 97.5
Height- 5’7
Weight- 100 lbs.
BMI- 15.7
General- Alert and oriented x3. Well groomed, patient appears tired.
Skin- Lips are cracked and dry, has calluses and abrasions on palms
of right hand.
HEENT- Hair appears thin, PERRLA, TMs are clear and intact, nasal
passageways clear, oropharynx clear. Poor condition of teeth,
erosion present.
Neck- Bilateral parotid swelling, no nodules. Thyroid normal in size.
Chest/lungs- Lungs are clear bilaterally, no rales, rhonchi or
wheezing.
Heart- Normal s1 and s2, no s3 or murmurs present.
Neuro- Crania nerves are intact.
Lab & Diagnostics
CBC- Normocytic normochromic anemia, mild leukopenia, mild
thrombocytopenia
CMP- Mild hyponatremia, hypokalemia, elevated BUN and
creatinine, elevated AST/ALT.
Thyroid function- Normal
HCG (urine)- Negative
EKG- Bradycardia present
Mental Status Exam
Appearance- appropriate for situation
Speech- normal
Eye contact- average for age
Motor activity- normal
Affect- full
Mood- anxious
Orientation- alert & oriented x3
Memory impairment- none observed
Attention- normal
Hallucinations- Denies AH/VH
Suicidality- Denies SI
Homicidality- Denies HI
Delusions- none
Behavior- poor insight and judgment, tearful throughout interview
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