Assignment 1:

Introduction

to the PMHNP SOAP Note

Introduction

The PMHNP SOAP note is a tool utilized to guide clinical reasoning to assess, diagnosis, and develop a treatment plan for a patient based on information presented and current evaluation of the patient. These notes serve as an important source of information about the health status of the patient and can be used to communicate this status to other health care professionals.

Instructions

Review the following resources: (See attachments)

• SOAP Note Presentation (PowerPoint)

  SOAP Note Presentation Transcript

• SOAP Note Template (Word)

1. Complete the SOAP Note Questionnaire and submit to this assignment. 

Background: I am currently enrolled in the Psych Mental Health Nurse Practitioner Program, I am a Registered Nurse, and I work in a Psychiatric Hospital.

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NU643: Advanced Psychopharmacology
Psychiatric SOAP Note Presentation
Slide 1:

Hi everyone. My name is Cassandra Godzik, nurse practitioner in the Regis College program. Today we are going to be talking about the psychiatric
SOAP note and how the SOAP note looks differently compared to the medical SOAP know that you might have seen in practice. There are some
major differences, and I want to be sure that we review and cover each component of the SOAP note so that you can know how to move forward
with the documentation.

Slide 2:

To get started, we are just going to cover what the psychiatric SOAP is, what it looks like, and then we are going to go into more detail about what it
actually includes. Be sure to take a look at the psychiatric SOAP note template that also goes along with this presentation. It will help you when you
are actually completing a SOAP note for a patient or a case study in the class.

Slide 3:

What exactly is a psychiatric SOAP note? SOAP notes are used for documenting patient care – what we see, what the plan is- the treatment plan for
our patients both in the medical setting and in the psychiatric setting. For both settings, the acronym is Subjective, Objective, Assessment, and
Plan, and within each of those components you are going to document information specific to that category. Again, it is a way to help us document,
organize our visits with our patients, and it can be a mixture of a bullet point and also written narrative, depending on your practice setting they will
require it be in narrative form in sentences. Other places it can be just quick bullet points, so definitely when you moved here clinical practice ask
about how they like you and expect clinicians to document. Again, it is slightly different from the medical SOAP note, and it is really that there is less
of a focus on the medical testing and review of systems that you might be familiar with from your health assessment course taken prior to this
course.

Slide 4:

Exactly what does it look like? It depends on the organization you work for. Some places it is still on paper and you have to document it in paper
form; others it is on the electronic health record so it might be on your computer or specific to the Internet at your setting. Really, the link varies on
the case. Sometimes if it’s a quick follow-up with the patient your psychiatric SOAP note will be really short. Other times you might have a more
intensive case that requires a lot more and there’s a lot more going on. You might have psychosis and substance use and social issues going on,
and that is going to mean that you’re going to have to evaluate more things and also make more of an effort on the treatment plan in terms of
medications and involvement of family and friends. In the psychiatric nurse practitioner program here at Regis it is important that we understand
what the psychiatric SOAP note looks like compared to the medical SOAP note. This is really just to help understand our patients and organize our
information to facilitate patient treatment planning and diagnosis.

Slide 5:

It is really a way for clinicians to communicate with each other, too. The four components are the Subjective, Objective, Assessment, and Plan. We
will go into detail on each of those.

Slide 6:

This is a slide that is taken right from the template that you can refer to it is also posted in Moodle. The S stands for Subjective, and it includes the
chief complaint, any subjective information (so what the patient tells you), as well as some basic demographic information from the patient. You also
want to include any relevant information to what is occurring at the moment, what the patient reports is happening, and some brief past medical
history and psychiatric history as well as social history.

Slide 7:

The components (this goes into more detail of the S, the Subjective section) and it helps break down exactly what should be included in this area of
your psychiatric SOAP note. This is really to help paint a picture and capture what this patient – what is happening for this patient in the moment, as
well as a little brief background about what happened prior to seeing this patient in clinic.

Slide 8:

The O is the Objective, so this is really the facts of the case. You want to think of it as what you would be able to actually monitor and assess at that
appointment. This could include vital signs. You might take vital signs in your clinic practice. It can also include lab results if they are in an ER
setting and they obtain labs peer there’s also mental status exam, which we do go into detail in another lesson plan, so definitely check that out to

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see specifically what needs to be included in that MSE. The MSE does need to be complete in a psychiatric up SOAP note so be sure that you are
documenting everything within the MSE. You will also document the risk assessment. The risk assessment is assessing if the patient is feeling safe,
if they have any suicidal ideation (thoughts or plans), homicidal ideation (thoughts/plans), or if there is any intent to go forth with those thoughts or
plans, as well as any contributory factors that are causing these thoughts and feelings as well as what in the patient’s life is helpful to prevent them
from moving forward with their plans. Again, that is also another lesson so be sure to take a look at what the risk assessment specifically includes.

Also, the psychiatric screening measure results, so depending on what your patient presents with in your practice, you are going to complete a
screening measurement. This could be the Hamilton Depression Screening Tool. This might be the AUDIT Tool, CAGE which is for substance use
and depression, there’s a whole host of them for ADHD and OCD, so depending on what you see with the patient you might choose to do one of the
screenings. Screenings can be found on different organization websites. There are some really good ones on the American Psychological
Association website and you might also consult with your mentor, your clinical preceptor, or faculty for additional tools. It is a good idea to start
putting together a toolbox for when you are in practice, so start thinking about that now.

Slide 9:

This just goes into more detail about the objective section. One thing I do want to really make clear in this section is the review of systems, so this is
really what makes the psychiatric SOAP note very different from the medical SOAP note. The review of systems in the psychiatric SOAP note is
very, very brief – very basic. You will be taking a quick review of the patient’s systems (is there any problems with your cardiac system, is there any
problem with breathing, shortness of breath? Are there any difficulties with their GI system?) You’re going to go through the systems very briefly,
and if there is nothing that is significant you are going to document that, it was noncontributory or nonsignificant. If there is a finding that is positive
you will just document that finding is positive, so if the patient is coming in with hand tremors you would want to document that. “;The review of
systems is noncontributory and negative except for hand tremors,”; so it is really very basic. Just include what is relevant and what is positive finding
whereas with your medical notes you will likely go into much greater detail with the cardiac system. You would want to find out a lot more
information, but this is just a real overview of any critical issues at this time.

Slide 10:

The A is the Assessment. Again this is on your template. Here you are going to go through what you found (diagnosis, differentials) so you want to
include what you think is the diagnosis that this person has. There might be one, there might be two, there might be a few that you would want to
include here. It might be based on a diagnosis you make. It might be a diagnosis that a previous clinician made, but you want to document that
here. The differentials are other diagnoses that you would want to consider, so things that you aren’t certain about at this time but you want to
continue to evaluate over time to see if the patient does, in fact, exhibit symptoms of that diagnosis. Somebody with symptoms of depression, you
might – and they are going through a difficult time. There’s situational issues in their life, you might not necessarily make the diagnosis of
depression, but instead have a differential diagnosis to continue evaluating them. As you collect more information you can make that determination
about whether you want to make it an actual diagnosis. You should look at the DSM V. That is where you will find the criteria for the diagnoses, so
take a look at those.

There’s also ICD 10 codes. These codes are for billing purposes. It is really important that you take a look to see what these ICD 10 codes are for
each diagnosis. They are challenging to learn in the beginning, and with some time I’m sure you will end up memorizing them actually for some of
the common ones. You can find the ICD 10 codes by googling them. There are some really good resources online for matching the DSM V
diagnoses to ICD 10 codes. A lot of your practice areas will require that you include the ICD 10 codes, so it’s a good idea to start practicing them
now. You are also going to include any treatment options for the patient, any recommendations that you are making based on the patient’s diagnosis
and any obstacles you expect that the patient might have moving forward with plans that you are going to go through in the upcoming slides.

Slide 11:

[No audio, written]

Aspects of “;A”;

Working primary diagnosis; current differential diagnoses; concurrent diagnoses including medical diagnoses; DSM V diagnoses, ICD 10 codes.

Slide 12:

Your P, the PE is really about the plan, so what are you doing? What is the plan for the patient going forward from this appointment on? You want to
include any medication changes you’ve made, any dosing changes, titration considerations, so if the patient is going to be seen in your office in a
week you want to include that information as well, and then you want to include any holistic options – if you recommended acupuncture or exercise,
if you have made any referrals to other psychiatric providers, therapists, medical providers you want to make sure to include that here as well.

Slide 13:

[No audio, written]

Aspects of “;P”;

Diagnostic: collateral information, releases obtained, safety planning, testing plans.

Specific treatment: medications (dose, route, titration plan), psychotherapy plans, education, nonpharmacologic interventions (nutrition, exercise).

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Disposition: Steps, follow-up plan, potential future treatment steps.

PMHNP SOAP Note questionnaire

Consulting the Answer Key, please answer the following questions:

1. What does the S stand for in the SOAP note format?

2. What information is contained in the S section?

3. What does the O stand for in the SOAP note format?

4. What information is contained in the O section?

5. What does the A stand for in the SOAP note format?

6. What information is contained in the A section?

7. What does the P stand for in the SOAP note format?

8. What information is contained in the P section?

9. What is the purpose of the PMHNP Soap Note?

10. Which section contains information that can be observed or measured?

11. Which section contains the differential diagnoses?

12. Which section contains the Mental Status Exam (MSE)?

Answer key:

These terms may be applicable to more than one question.

· Subjective

· Guides clinical reasoning, diagnosis, and treatment decisions; facilitates communication among providers, tracks progress

· Objective

· Chief complaint, demographic information, HPI, PMH, Social History

· Plan

· Assessment

· VS, ROS, MSE, labs, screening assessments, “facts”

· Diagnosis and differential diagnoses, DSM-5 criteria, and potential treatment options

· Specific instructions for medications and dosing, lab work ordered, referrals, therapy recommendations, follow up

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.

CG&AM&BF_10/10/18

Psychiatric SOAP Note Presentation

Regis College

PMHNP Program

Edited 10-14-18, AM, CG & BF

Outline
What is Psychiatric SOAP Note?
What does it look like?
What does it include?
Breakdown of S, O, A, P

What is a Psychiatric SOAP Note?
SOAP
Subjective
Objective
Assessment
Plan
SOAP is a way to help track progress of patients
Helps with documentation, organization
Done at each visit
Mix of bullet points, narrative
Different from medical SOAP note
Less focus on medical testing, review of systems

What does SOAP look like?
Dependent on the organization you work for
Electronic health record (EHR), paper forms
Length varies on case
Purposes in PMHNP Program
Need to show application of materials to patient cases
Understand resources available as students and future clinicians
Simplifies and promotes organization of information to facilitate diagnosis and treatment planning

What does SOAP include?
4 Components
Subjective
Objective
Assessment
Plan

“S” Subjective from PMHNP SOAP Template
Criteria Clinical Notes
Subjective  
Include chief complaint, subjective information from the patient, names and relations of others present in the interview, and basic demographic information of the patient. HPI, Past Medical and Psychiatric History, Social History.

Aspects of “S”
Chief Complaint, description
Subjective Information: name, date of birth, sex, identifying data, preference for name/pronouns
Location of Interview
People Present for Interview
History of the Present Illness (HPI) which documents the patient’s current condition
Medical History: diagnoses, medical hospitalizations, medical and surgical procedures, head and body trauma (loss of consciousness, concussions)
Psychiatric History: psychiatric hospitalizations, partial hospitalizations, intensive outpatient programs, residential program treatment, individual and groups therapies, ECT/TMS/Ketamine Treatments, past suicide/homicide attempts, self-injurious behaviors
Family Psychiatric History: suicides, homicides, attempts, long-term institutional treatment of family
Medication History: vitamins, psychotropic and other medications, birth control, relevant blood work and tests
Social History: school completion, work history, legal history, living situation
Substance Use: Alcohol, Drugs (oral and injectable and inhalation routes considered), Smoking Status – current and past

“O” Objective from PMHNP SOAP Template

Criteria Clinical Notes
Objective  
This is where the “facts” are located. Include relevant labs, test results, vitals, and Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…” Include MSE, risk assessment here, and psychiatric screening measure results.

Aspects of “O”
Patient’s physical appearance with descriptive words
Review of Systems (ROS): not as extensive as medical ROS, “ROS noncontributory” or “ROS negative except for …” Document abnormal findings like “shuffling, tremors,” etc.
Vital signs, if available
Lab results, if available
Complete Mental Status Exam (MSE)
Risk Assessment
Screening Results – Measures like the CAGE, AUDIT, etc.

“A” Assessment from PMHNP SOAP Template

Criteria Clinical Notes
Assessment  
Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment.

Aspects of “A”
Working primary diagnoses
Current differential diagnoses
Concurrent diagnoses including Medical Diagnoses
DSM-V diagnoses, ICD-10 codes

“P” Plan from PMHNP SOAP Template

Criteria Clinical Notes
Plan  
Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options and complimentary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment.

Aspects of “P”
Diagnostic: collateral information, releases obtained, safety planning, testing plans
Specific Treatment: medications (dose, route, titration plan), psychotherapy plans, education, non-pharmacologic interventions: nutrition, exercise
Disposition: next steps, follow-up plan, potential future treatment steps