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For this assignment you can use any fictitious patient (psychiatric diagnosis such as MMD, PTSD, GAD) just made sure that you follow the template for the SOAP note

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For this assignment you can use any fictitious patient (psychiatric diagnosis such as MMD, PTSD, GAD) just made sure that you follow the template for the SOAP note. Thnak you

SOAP Note Template

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(Use this template for this assignment)

 

Demographic Data

· Patient age and gender identity

· MUST BE HIPAA compliant

Subjective

Chief Complaint (CC)

· Place the complaint in Quotes

· Brief description -only a few words and in the patient’s words…“My chest hurts”, “I cannot breath”, “I passed out”, etc.

History of Present Illness (HPI) – the reason for the appointment today

· Use the OLD CARTS acronym to document the eight elements of a chief concern (CC): Onset, Location/radiation, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity)

· Briefly describe the general state of health prior to the problem.

· Are Activities of Daily Living (ADL) impacted by the current problem?

 

Past Medical History:

· List current and past medical diagnoses

 

Past Surgical History:

· List all past surgeries

 

FAMILY HISTORY:

· Include medical/psychiatric problems to include 3 generations (parents, grandparents, siblings, or direct relatives.

 

Current Medications:

· Include current prescription(s), over-the-counter medications, herbal/alternative medications as well as vitamin/supplement use.

 

ALLERGIES: Include medications, foods, and chemicals such as latex.

 

Immunizations History: List current immunization status and address deficiency

 

Preventative health History: (See Table below – Appendix A)

 

SOCIAL HISTORY:

· Include nutrition, exercise, substance use (details of use: caffeine, EtOH, illicit drug use), sexual history/preference, financial problems, legal issues, kids, and history of abuse, including sexual, emotional, or physical.

· Employment/Education: occupation (type), exposure to harmful agents, highest school achievement

 

 

REVIEW OF SYSTEMS:

· A ROS is a question-seeking inventory by body systems to identify signs and/or symptoms that the patient may be experiencing or has experienced.

· Must include any physical complaint(s) by the body system that is relevant to treatment and management of the current concern(s). List only the pertinent body systems specific to the CC.

· Remember to include pertinent positive and negative findings when detailing the ROS related to a chief concern (CC).

· Do not repeat the information provided in HPI

· Use the format below when detailing the ROS

 

 

ROS:

 

General:

Eyes:

Ears, nose, mouth & throat:

Cardiovascular:

Respiratory:

Gastrointestinal:

Skin & Breasts:

Musculoskeletal:

Allergic:

Immunologic:

Endocrine:

Hematopoietic/Lymphatic:

Genitourinary:

Neurological:

Psychiatric/Mental Status:

 

 

 

 

 

Objective

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