Every other week students will choose one patient encounter to submit a Follow-up SOAP note for review.  Follow the rubric to develop your SOAP notes for this term.  The focus is on you

Criteria

Clinical Notes

Informed Consent

Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits

Subjective

Verify Patient

Name: Heldi

DOB: 14 years

Minor: NA

Accompanied by: mother

Demographic: NA

Gender Identifier Note: Female

CC: “I lie on bed all doing nothing and have thoughts of dying”

.

HPI: the patient reports to the healthcare clinic accompanied by the mother reporting several symptoms. The patient states that she has been having thoughts about dying and that she has been feeling flat.

Pertinent history in record and from patient: depression and self harm

During assessment: Patient is calm and corparative. She is X3 oriented. The patient says she cannot take it anymore.

SI/ HI/ AV: patient says that she has been having suicidal ideation and has several times harmed herself through cutting.

Allergies: NKDFA.

(medication & food)

Past Medical Hx:

Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury.

Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C.

Surgical history no surgical history reported

Past Psychiatric Hx: depression

Previous psychiatric diagnoses: NKDA

Describes stable course of illness.

Previous medication trials: not reported

Safety concerns:

History of Violence to Self: reported

History of Violence t o Others: none reported

Auditory Hallucinations: not reported

Mental health treatment history discussed:

History of outpatient treatment: not reported

Previous psychiatric hospitalizations: not reported

Prior substance abuse treatment: not reported

Trauma history: Client reveals no history of traumatic experiences (such as abuse, domestic violence, or exposure to upsetting events).

Substance Use: the patient does not reports alcohol abuse

Client report taking alcohol.

Current Medications: NKDA

(Contraceptives):

Supplements:

Past Psych Med Trials: depression

Family Medical Hx: not reported

Family Psychiatric Hx: not reported

Substance use –NKDA

Suicides-not reported

Psychiatric diagnoses/hospitalization-not reported

Developmental diagnoses

Social History:

Occupational History: NKD.

Military service History: Denies previous military hx.

Education history: completed HS and vocational certificate

Developmental History: no significant details reported.

(Childhood History include in utero if available)

Legal History: no reported/known legal issues,no reported/known conservator or guardian.

Spiritual/Cultural Considerations: none reported.

ROS:

Constitutional: no fever reported.

Eyes: No report of acute vision changes or eye pain.

ENT: No report of hearing changes or difficulty swallowing.

Cardiac: No report of chest pain, edema or orthopnea.

Respiratory: Denies dyspnea, cough or wheeze.

GI: reports abdominal pain.

GU: No report of dysuria or hematuria.

Musculoskeletal: No report of joint pain or swelling.

Skin: No report of rash, lesion, abrasions.

Neurologic: No report of seizures, blackout, numbness or focal weakness. Endocrine: No report of polyuria or polydipsia.

Hematologic: No report of blood clots or easy bleeding.

Allergy: No report of hives or allergic reaction.

Reproductive: No report of significant issues. (females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…)

Verify Patient: Name, Assigned identification number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo.

Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview.

HPI:

, Past Medical and Psychiatric History,

Current Medications, Previous Psych Med trials,

Allergies.

Social History, Family History.

Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…”

Objective

Vital Signs: Stable

This is where the “facts” are located.

Vitals,

**Physical Exam (if performed, will not be performed every visit in every setting)

Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results.

Assessment

DSM5 Diagnosis: with ICD-10 codes

Dx: – Major depression disorder ICD-10-CM Code F32.1

Dx: Generalized anxiety disorder ICD-10-CM Code F41.1

Dx: post-traumatic stress disorder (PTSD) ICD-10 F43.1

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.

Informed Consent Ability

Plan

(Note some items may only be applicable in the inpatient environment)

Inpatient:

Psychiatric. depression

Estimated stay

Safety Risk/Plan: Patient is found to be stable and has control of behavior. Patient likely poses a minimal risk to self and a minimal risk to others at this time.

Patient denies abnormal perceptions and does not appear to be responding to internal stimuli.

Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic:

The patient is put on paxil 10 mg orally daily until she stablizes. As a preventative measure, this medicine may be started by those who suffer from depression (Mullen, 2018). This is the go-to therapy for this disease, and it's just as effective as SSRIs. Contrasted to tricyclic antidepressants, these medications have less negative side effects.

CBT is also the psychotherapist of choice for dealing depression. In this phase, the patient and therapist will talk about ways to lessen the severity of the symptoms. Catering to students' emotional, social, and physical well-being as part of their academic curriculum. In addition to medication, psychoeducational therapy for the afflicted person and their family is strongly suggested (Flanagan, et al., 2015).

Follow-up, including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit 4 weeks

☒>50% time spent counseling/coordination of care.

Time spent in Psychotherapy 18 minutes

Visit lasted 55 minutes

Billing Codes for visit:

XX

XX

XX

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NAME, TITLE

Date: Click here to enter a date.Time: X