Initial Psychiatric Interview/SOAP Note Template
| 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, and (Will review additional consent during treatment plan discussion) |
| Subjective | Verify Patient
Name: Susan DOB: not provided
Minor: NA Accompanied by: self
Demographic: NA
Gender Identifier Note: Female
CC: “I have been feeling anxious, depresssed, high blood pressure, irregular heartbeat, elevated body temperature, crying spells for the last 2 days†.
HPI: Susan is a midde aged woman who reports to the healthcare clinic reporting several symptoms that she has observed over the period of the last two days. She reports having high blood pressure, an irregular heartbeat, depression, anxiety, and an increase in body temperature. Susan doesn’t realize that she shows signs of alcohol dependence and physiological dependence, which downplays the seriousness of her alcohol usage. This diagnosis is supported by the withdrawal symptoms that appear to be becoming more tolerable as well as by the sustained and increased alcohol consumption despite the harm it does to social interactions and job performance. She has also increased her alcohol consumption to ease withdrawal symptoms. s He has a history of drinking, which has caused him to skip work and even get arrested. She downplays her alcohol consumption and justifies how often and how much she drinks.
Pertinent history in record and from patient: Alcohol withdrawal
During assessment: Patient is cam and corparative
Patient seemed to be suffering from serious cases of both anxiety and despair judging from her crying spells.
Patient denies hallucinating. The patient has nomal thought process. .
SI/ HI/ AV: patient denies signs of suicidal ideation and violent behavior.
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: Previous psychiatric diagnoses: NKDA Describes stable course of illness. Previous medication trials: not reported Safety concerns: History of Violence to Self:none 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 Priorsubstance 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 reports alcohol abuse Client does report abuse of or dependence on alcohol.
Current Medications: NKDA (Contraceptives): Supplements:
Past Psych Med Trials: alcohol use disorder
Family Medical Hx: not repported
Family Psychiatric Hx: not reported Substance use –alcohol abuse Suicides-not reported Psychiatric diagnoses/hospitalization-not reported Developmental diagnoses
Social History: Occupational History: currently unemployed. 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: increased 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
Temp:98.4 BP:124/78 HR:96 R:20 O2:100% Pain: Ht: 5’5†Wt:120 BMI: 20.0 BMI Range: Heathy weight
LABS: Lab findings abnomal Hepatic function Tox screen: positive Alcohol: positive HCG: N/A
Physical Exam: MSE: Patient is fully oriented. Patient is dressed appropriately for age and season. Psychomotor activity appears within normal. Presents with coherent speech, expansive, slowed rate. TC: no abnormal content elicited, denies suicidal ideation and denieshomicidal ideation. Process appears linear, coherent, goal-directed. Cognition appears grossly intact with appropriateattention span & concentration and average fund of knowledge. Judgment appears fair . Insight appearsfair
The patient is able to articulate needs, is motivated for compliance and adherence to medication regimen. Patient is willing and able to participate with treatment, disposition, and discharge planning.
|
| 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: – Alcohol dependence with withdrawal, unspecified ICD-10-CM Code F10.239 Dx: – Alcohol intoxication ICD-10-CM Code F10.22 Dx: – – Sedative-hypnotic ICD-10-CM Code F13.231
Patient has the ability/capacity appears to respond to psychiatric medications/psychotherapy and appears to understand the need for medications/psychotherapy and is willing to maintain adherent. Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment. |
| 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. NKDA 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 Zoloft 75mg until she stablizes. She will be taking 75 milligrams of Zoloft until her condition stabilizes. Depression and anxiety are common among those who abuse alcohol, and zoloft may help alleviate these symptoms. Likewise, cognitive behavioral therapy (CBT) is the psychotherapist of choice for treating alcohol dependence (Gibney, 2018). Here, the patient and therapist will discuss potential strategies for mitigating the impact of the symptoms. Providing for the psychological, social, and physical needs of students in their educational programs. Medication is key, but psychoeducational counseling for the affected individual and their family members is also highly recommended (Johansson, et al., 2021).
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
____________________________________________ NAME, TITLE
Date: Click here to enter a date.Time: X
|
References
Gibney, S. (2018). An Unfinished Story, an Unfinished Body: How Missing Health Histories Predispose Adoptees to Illness.  Narrative Inquiry in Bioethics,  8(2), 109-111. Project MUSE – An Unfinished Story, an Unfinished Body: How Missing Health Histories Predispose Adoptees to Illness (jhu.edu)
Johansson, M., Berman, A. H., Sinadinovic, K., Lindner, P., Hermansson, U., & Andréasson, S. (2021). Effects of internet-based cognitive behavioral therapy for harmful alcohol use and alcohol dependence as self-help or with therapist guidance: three-armed randomized trial.  Journal of medical Internet research,  23(11), e29666. Journal of Medical Internet Research – Effects of Internet-Based Cognitive Behavioral Therapy for Harmful Alcohol Use and Alcohol Dependence as Self-help or With Therapist Guidance: Three-Armed Randomized Trial (jmir.org)
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Initial Psychiatric Interview/SOAP Note Template
| 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, and (Will review additional consent during treatment plan discussion) |
| Subjective | Verify Patient
Name: Susan DOB: not provided
Minor: NA Accompanied by: self
Demographic: NA
Gender Identifier Note: Female
CC: “I have been feeling anxious, depresssed, high blood pressure, irregular heartbeat, elevated body temperature, crying spells for the last 2 days†.
HPI: Susan is a midde aged woman who reports to the healthcare clinic reporting several symptoms that she has observed over the period of the last two days. She reports having high blood pressure, an irregular heartbeat, depression, anxiety, and an increase in body temperature. Susan doesn’t realize that she shows signs of alcohol dependence and physiological dependence, which downplays the seriousness of her alcohol usage. This diagnosis is supported by the withdrawal symptoms that appear to be becoming more tolerable as well as by the sustained and increased alcohol consumption despite the harm it does to social interactions and job performance. She has also increased her alcohol consumption to ease withdrawal symptoms. s He has a history of drinking, which has caused him to skip work and even get arrested. She downplays her alcohol consumption and justifies how often and how much she drinks.
Pertinent history in record and from patient: Alcohol withdrawal
During assessment: Patient is cam and corparative
Patient seemed to be suffering from serious cases of both anxiety and despair judging from her crying spells.
Patient denies hallucinating. The patient has nomal thought process. .
SI/ HI/ AV: patient denies signs of suicidal ideation and violent behavior.
Allergies: NKDFA. (medication & food)
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: Previous psychiatric diagnoses: NKDA Describes stable course of illness. Previous medication trials: not reported Safety concerns: History of Violence to Self:none 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 Priorsubstance 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 reports alcohol abuse Client does report abuse of or dependence on alcohol.
Current Medications: NKDA (Contraceptives): Supplements:
Past Psych Med Trials: alcohol use disorder
Family Medical Hx: not repported
Family Psychiatric Hx: not reported Substance use –alcohol abuse Suicides-not reported Psychiatric diagnoses/hospitalization-not reported Developmental diagnoses
Social History: Occupational History: currently unemployed. 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: increased 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
Temp:98.4 BP:124/78 HR:96 R:20 O2:100% |
Are you busy and do not have time to handle your assignment? Are you scared that your paper will not make the grade? Do you have responsibilities that may hinder you from turning in your assignment on time? Are you tired and can barely handle your assignment? Are your grades inconsistent?
Whichever your reason is, it is valid! You can get professional academic help from our service at affordable rates. We have a team of professional academic writers who can handle all your assignments.
Students barely have time to read. We got you! Have your literature essay or book review written without having the hassle of reading the book. You can get your literature paper custom-written for you by our literature specialists.
Do you struggle with finance? No need to torture yourself if finance is not your cup of tea. You can order your finance paper from our academic writing service and get 100% original work from competent finance experts.
Computer science is a tough subject. Fortunately, our computer science experts are up to the match. No need to stress and have sleepless nights. Our academic writers will tackle all your computer science assignments and deliver them on time. Let us handle all your python, java, ruby, JavaScript, php , C+ assignments!
While psychology may be an interesting subject, you may lack sufficient time to handle your assignments. Don’t despair; by using our academic writing service, you can be assured of perfect grades. Moreover, your grades will be consistent.
Engineering is quite a demanding subject. Students face a lot of pressure and barely have enough time to do what they love to do. Our academic writing service got you covered! Our engineering specialists follow the paper instructions and ensure timely delivery of the paper.
In the nursing course, you may have difficulties with literature reviews, annotated bibliographies, critical essays, and other assignments. Our nursing assignment writers will offer you professional nursing paper help at low prices.
Truth be told, sociology papers can be quite exhausting. Our academic writing service relieves you of fatigue, pressure, and stress. You can relax and have peace of mind as our academic writers handle your sociology assignment.
We take pride in having some of the best business writers in the industry. Our business writers have a lot of experience in the field. They are reliable, and you can be assured of a high-grade paper. They are able to handle business papers of any subject, length, deadline, and difficulty!
We boast of having some of the most experienced statistics experts in the industry. Our statistics experts have diverse skills, expertise, and knowledge to handle any kind of assignment. They have access to all kinds of software to get your assignment done.
Writing a law essay may prove to be an insurmountable obstacle, especially when you need to know the peculiarities of the legislative framework. Take advantage of our top-notch law specialists and get superb grades and 100% satisfaction.
We have highlighted some of the most popular subjects we handle above. Those are just a tip of the iceberg. We deal in all academic disciplines since our writers are as diverse. They have been drawn from across all disciplines, and orders are assigned to those writers believed to be the best in the field. In a nutshell, there is no task we cannot handle; all you need to do is place your order with us. As long as your instructions are clear, just trust we shall deliver irrespective of the discipline.
Our essay writers are graduates with bachelor's, masters, Ph.D., and doctorate degrees in various subjects. The minimum requirement to be an essay writer with our essay writing service is to have a college degree. All our academic writers have a minimum of two years of academic writing. We have a stringent recruitment process to ensure that we get only the most competent essay writers in the industry. We also ensure that the writers are handsomely compensated for their value. The majority of our writers are native English speakers. As such, the fluency of language and grammar is impeccable.
There is a very low likelihood that you won’t like the paper.
Not at all. All papers are written from scratch. There is no way your tutor or instructor will realize that you did not write the paper yourself. In fact, we recommend using our assignment help services for consistent results.
We check all papers for plagiarism before we submit them. We use powerful plagiarism checking software such as SafeAssign, LopesWrite, and Turnitin. We also upload the plagiarism report so that you can review it. We understand that plagiarism is academic suicide. We would not take the risk of submitting plagiarized work and jeopardize your academic journey. Furthermore, we do not sell or use prewritten papers, and each paper is written from scratch.
You determine when you get the paper by setting the deadline when placing the order. All papers are delivered within the deadline. We are well aware that we operate in a time-sensitive industry. As such, we have laid out strategies to ensure that the client receives the paper on time and they never miss the deadline. We understand that papers that are submitted late have some points deducted. We do not want you to miss any points due to late submission. We work on beating deadlines by huge margins in order to ensure that you have ample time to review the paper before you submit it.
We have a privacy and confidentiality policy that guides our work. We NEVER share any customer information with third parties. Noone will ever know that you used our assignment help services. It’s only between you and us. We are bound by our policies to protect the customer’s identity and information. All your information, such as your names, phone number, email, order information, and so on, are protected. We have robust security systems that ensure that your data is protected. Hacking our systems is close to impossible, and it has never happened.
You fill all the paper instructions in the order form. Make sure you include all the helpful materials so that our academic writers can deliver the perfect paper. It will also help to eliminate unnecessary revisions.
Proceed to pay for the paper so that it can be assigned to one of our expert academic writers. The paper subject is matched with the writer’s area of specialization.
You communicate with the writer and know about the progress of the paper. The client can ask the writer for drafts of the paper. The client can upload extra material and include additional instructions from the lecturer. Receive a paper.
The paper is sent to your email and uploaded to your personal account. You also get a plagiarism report attached to your paper.
GET A PERFECT SCORE!!!
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