SOAP Note

Basic Information

Age:

Gender:

Male Female

Reason for Referral: Select reason for referral Psychological Assessment Neuropsychological Evaluation IQ Testing Personality Assessment Psychotherapy Psychological Counseling Medication Refill Walk-In

Marital Status: Single Married Divorced Widowed Separated Engaged Unmarried Prefer not to say

Occupation:

SUBJECTIVE Information

Progress & Improvement:

1st visit Deterioration Same level of functioning No or little improvement Partial improvement Significant improvement Full recovery

Pt's Complaints: (Write only the symptoms)

Patient's Mood (As Pt described it):

Normal Depressive Anger Nervous Anxious Indifferent Happy Euphoric Irritable Lonely Other

Appetite:

Good Normal Poor Increased Decreased Other

Sleep Information: (list only the symptoms when selecting "problematic")

Sleep: Normal Problematic

Describe the Problem:

Energy Level:

Good Normal Poor High Low Variable Crashing No energy Other

Occupational Performance:

Not applicable Outstanding Good Satisfactory Mediocre Improving Declining Inadequate Unsatisfactory Poor Erratic Other

Academic Performance (if applicable):

Not Applicable Outstanding Excellent Good Satisfactory Mediocre Improving Declining Inadequate Unsatisfactory Poor Failing Other

Compliance with Medication:

Fully compliant Partially compliant Non-compliant Not on medication

Substance Use:

Denied Past History but No Current Use Enter the name of substance(s), and when; for example: Alcohol, five years ago. Clear Selection

Alcohol Write the quantity and frequency. For example: 3 drinks per day

Tobacco Write the quantity and frequency. For example: 20 cigarettes per day

Cannabis Write the quantity and frequency. For example: 1 joint per day

Hallucinogen Write the quantity and frequency. For example: 1 dose per month

Stimulants Write the quantity and frequency. For example: 2 tablets per week

Opioids Write the quantity and frequency. For example: 1 dose per day

Caffeine Write the quantity and frequency. For example: 16 cups of coffee per day

Inhalants Write the quantity and frequency. For example: 1 session per week

Illicit Drugs Write the quantity and frequency. For example: 2 uses per month

Risky Behavior

History of Self-Harm: Denied Ideation Attempts

Write the details based on Pt's story, remember that it starts with "Pt reported", you need to complete after this.

Current Self-Harm: Denied Ideation Attempts

Write the details based on Pt's story, remember that it starts with "Pt reported", you need to complete after this.

History of Other-Harm: Denied Ideation Attempts

Write the details based on Pt's story, remember that it starts with "Pt reported", you need to complete after this.

Current Other-Harm: Denied Ideation Attempts

Write the details based on Pt's story, remember that it starts with "Pt reported", you need to complete after this.

Passive Death Wishes: No Yes

OBJECTIVE

Alertness and Orientation:

Alertness:

Alert Drowsy Stuporous Comatose

Orientation:

Oriented to time, place, and person Oriented to time and place, but not person Oriented to time, but not place or person Disoriented to time, place, and person Oriented to time and place, but not person Oriented only to place, but not to time nor person Oriented to person, but not to time or place

The assessment is not possible as Pt is in coma.

Appearance:

Clean and well-groomed Disheveled Unkempt Neatly dressed Traditionally dressed Inappropriately dressed Malodorous Eccentric clothing Younger than stated age Older than stated age Other

Physical Features:

Emaciated Obese Cachectic Pallor Jaundiced Cyanotic Flushed Tremulous Well-nourished Other

Posture and Movements:

Normal Activity Level Upright posture Slumped posture Restless Hyperactive Hypoactive Agitated Tremors Tics Bradykinesia Akathisia

Cooperativeness:

Cooperative Uncooperative

Attitude:

Friendly Engaged Open Hostile Indifferent Shy Guarded Playful Defensive Avoidant Evasive Polite Motivated Anxious Resistant Challenging Aloof Respectful Disrespectful Other

Attention and Concentration:

Normal attention span and concentration Easily distracted Difficulty focusing Hyperfocused

Speech:

General Speech Ability:

Able to speak Unable to speak for medical/psychological reason

Spontaneity:

Normal Poverty of Speech Mutism

Rate:

Slow Normal Pressured

Volume:

Soft Normal Loud

Rhythm & Fluency:

Halting Normal Stuttering Blocking

Tone:

Normal Monotone Emotional

Articulation & Pronunciation:

Normal Slurred Mumble

Prosody:

Normal Flat Inappropriate

Appropriateness to Age:

Below expected level from age Within expected level from age Above expected level from age

Grammar:

Normal Grammatical errors

Mood (as described by patient):

Affect (as observed by examiner):

Congruent with mood Not congruent with mood
Appropriate to situation Flat Blunted Labile Exaggerated Restricted/Constricted Other

Thought Process:

Flow of Ideas

Linear (logical and goal-directed) Tangential (diverges from the main topic) Circumstantial (excessive detail but eventually reaches the point) Flight of Ideas (rapid shifts between topics) Loosening of Associations (illogical or disconnected ideas) Thought Blocking (sudden interruption of thought)

Coherence

Coherent (understandable and logical) Incoherent (disorganized and nonsensical) Word Salad (random mix of words)

Speed

Normal Rapid (fast, pressured) Slow (delayed responses)

Thought Form:

Logical Structure

Logical (thoughts progress in a straight line, logical and goal-directed) Illogical (disconnected and bizarre)

Continuity

Normal (smooth and continuous) Fragmented (incomplete thoughts) Perseveration (repetition of the same response)

Goal-Directedness

Normal (goal-oriented) Wandering (difficulty staying on topic) Derailment (abrupt changes in topic)

Thought Content:

Preoccupation with current problems Preoccupation with the past Preoccupation with the future Delusions Obsessions Worries Phobias Suicidal Ideation Homicidal Ideation Other Just enter the topic Pt preoccupied with. For example, "his children future", "Her academic performance".

Psychotic and Perceptual Abnormalities

No signs of psychotic features or perceptual abnormalities Signs of psychotic features or perceptual abnormalities present

Delusions:

Absence Presence

--Please specify-- Persecutory Referential Somatic Religious Grandiose Erotomanic Nihilistic Unspecified

Hallucination:

Absence Presence

--Please specify-- Auditory Visual Olfactory Tactile

Disorganized Thinking/Speech:

Absence Presence

--Please specify-- Derailment Tangentiality Word Salad

Abnormal Motor Behavior:

Absence Presence

--Please specify-- Catatonic behavior

Negative Symptoms:

Absence Presence

--Please specify-- Diminished Emotional Expression Avolition Alogia Anhedonia Asociality

Memory:

Immediate Memory: Excellent Normal Impaired
Working Memory: Excellent Normal Impaired
Short Term Memory: Excellent Normal Impaired
Long-Term Memory: Excellent Normal Impaired

Other Cognitive Functions:

Abstract Thinking: Intact Impaired
Insight: Good Fair Poor
Judgment: Good Fair Poor
Cognitive Function: Grossly Intact Grossly Not Intact

ASSESSMENT

Risk Assessment

Low Moderate High

Logic of Assessment

Nature of condition Previous Hx Having active ideation Having active plan Having active means Other

Diagnostic Impression

Differential Diagnosis

Differential Diagnosis

Provisional Diagnosis

Provisional Diagnosis

Diagnosis for Rule Out

Diagnosis for Rule Out

Does not meet criteria

Does not meet any full criteria for mental disorders

Need further assessment

Need further assessment

Comorbid Conditions: (Physical or Psychological)

Treatment Response and Progress

1st visit Deterioration No improvement Slight Improvement Partial Improvement Significant Improvement Full Recovery

PLAN

Long Term Goals

Goal(s):

Short Term Goals

Goal(s):

Today's Intervention

Psychotropic Medication (dosage, frequency):

Psychotherapy (type, frequency/duration):

Psychometric Assessment (type, results):

Psycho-education

Psychological Counseling

Safety Management (if needed)

Referral (if needed)

Follow-up Date

Reason for Follow-up: