A Soap Note

SOAP (Psych) Notes
Students will be required to complete one SOAP (psych) note on a patient seen in the practicum setting each week. These need to follow the guidelines for writing SOAP notes (S = Subjective, O = Objective, A = Assessment, P = Plan) and include relevant history, physical findings, assessment, and interventions.


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Student Name: ________________________________________Patient Initial____________

Patient Information
􀁸 Gender
􀁸 Height and Weight
􀁸 Marital status
􀁸 Occupation
􀁸 Current medication
􀁸 Past Psychiatric medication
􀁸 Allergies

􀁸 Chief complaint: describe the reason for the visit and chief complaint
􀁸 Describe history of present illness, including analysis of symptoms
􀁸 Medical history
􀁸 Psychiatric history (age of onset, diagnosis, previous treatments, hospitalization)
􀁸 Family history
􀁸 Psychosocial/Developmental History
􀁸 Substance Use History
􀁸 Current or Past Legal History
􀁸 Current or Past Truma
􀁸 Current or Past Abuse
􀁸 Review of Systems (no significant issues revealed, CV, Renal, GI, Hepatic, CNS, GU, CA, Metabolic, Pulm, GYN, HIV)

􀁸 Mental Staus exam
􀁸 Screening tests/symptom scales Performed
􀁸 Strengths/Limitations
􀁸 Include any objective data you have now, including labs

􀁸 Identify diagnosis, including differential diagnosis and rationale
􀁸 Case Formulation

􀁸 List plan of care, including medication (Evidence Based Practice) and rationale
􀁸 Describe any needed lab work with rationale
􀁸 Identify alternatives to this plan
􀁸 Referrals
􀁸 How soon should the patient return for follow-up and why?
􀁸 Was this patient an appropriate patient for a nurse practitioner? Is a nurse practitioner the
appropriate provider of follow-up care for this patient?
􀁸 Was this a health care encounter that required consultation or collaboration with another
health care provider?
􀁸 If yes, to whom should the patient be referred? Is this type of provider available in the

􀁸 What education does this patient/family need?
􀁸 What community resources are available in the provision of care for this client? For more information on A Soap Note visit this: https://en.wikipedia.org/wiki/SOAP_note

A Soap Note

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