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.
OSCE SOAP (Psych)NOTE
REQUIRED ELEMENTS OF THE SOAP (psych)NOTE
Student Name: ________________________________________Patient Initial____________
Height and Weight
Past Psychiatric medication
Chief complaint: describe the reason for the visit and chief complaint
Describe history of present illness, including analysis of symptoms
Psychiatric history (age of onset, diagnosis, previous treatments, hospitalization)
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
Include any objective data you have now, including labs
Identify diagnosis, including differential diagnosis and rationale
List plan of care, including medication (Evidence Based Practice) and rationale
Describe any needed lab work with rationale
Identify alternatives to this plan
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
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