NU675: Unit 3: Assignment Clinical SOAP Note

NU675: Unit 3: Assignment Clinical SOAP Note

 
Clinical SOAP Note

Initial Psychiatric Interview/SOAP Note Template 

Criteria

Clinical Notes

 

Informed Consent

Informed consent was obtained prior to the psychiatric interview. The patient was informed of the nature and purpose of the psychiatric assessment, medication management, and psychotherapy, including risks, benefits, and alternatives to treatment. Verbal and written consent were obtained. The patient demonstrated adequate decisional capacity, was able to respond appropriately to questions, and verbalized understanding of the treatment process. Additional informed consent will be reviewed as part of the ongoing treatment plan.

Subjective

Verify Patient

Name: S.G.

DOB: 10/12/1983

 

Minor: No

Accompanied by: Self

 

Demographic: 42-year-old African American female

 

Gender Identifier Note: Identifies as female

 

CC: “My anxiety is better, but I’m still having trouble sleeping and I have very low motivation.”

 

HPI: S.G. is a 42-year-old female with a history of generalized anxiety disorder (GAD) and major depressive disorder (MDD), recurrent, moderate, who presents for a scheduled 4-week follow-up. She reports significant improvement in anxiety symptoms since her last visit and the initiation of escitalopram 10 mg daily, noting a marked reduction in daily worry and panic attacks. However, she endorses persistent insomnia, characterized by prolonged sleep latency and frequent nocturnal awakenings, which she rates as 6/10 in severity. Concurrently, she reports persistent depressive symptoms including low energy, anhedonia, poor concentration, and low motivation, which have impaired her work performance as a graphic designer. She denies active suicidal or homicidal ideation, intent, or plan. She has been fully adherent to her medication regimen and denies adverse effects. She continues biweekly cognitive behavioral therapy (CBT) sessions, which she finds beneficial yet emotionally taxing.

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SI/ HI/ AV: Patient currently denies suicidal ideation, denies self-injurious behaviors, denies homicidal ideation, denies violent behavior, and denies inappropriate or illegal behaviors.

 

Allergies: NKA.

(medication & food)

 

Past Medical Hx:

Medical history: Reports hypothyroidism, stable on levothyroxine, and episodic migraine without aura.

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: major depressive disorder and generalized anxiety disorder.

Describes stable but fluctuating course of illness.

Previous medication trials
: sertraline (discontinued due to gastrointestinal intolerance) and venlafaxine (partial response).

 

Safety concerns:

History of Violence
to Self:
  none reported

History of Violence t
o Others
: none reported

Auditory Hallucinations: Denied

Visual Hallucinations: Denied

 

Mental health treatment history
discussed:

History of outpatient treatment: Ongoing CBT since 2020

Previous psychiatric hospitalizations: not reported

Prior substance abuse treatment: not reported

 

Trauma history:
Client does not report history of trauma including abuse, domestic violence, witnessing disturbing events NU675: Unit 3: Assignment Clinical SOAP Note.

 

Substance Use:
Client denies use or dependence on nicotine/tobacco products.

Client does not report abuse of or dependence on ETOH, and other illicit drugs.

 

Current Medications: Escitalopram 10 mg PO daily, Levothyroxine 75 mcg PO daily, Ibuprofen 400 mg PO PRN headache.

(Contraceptives): None reported

Supplements: None reported

 

Past Psych Med Trials: Sertraline; Venlafaxine

 

Family Medical Hx:

·        Mother: Major Depressive Disorder

·        Father: Hypertension

·        Paternal brother: Alcohol Use Disorder

 

Family Psychiatric Hx:

·        Substance use: paternal brother

·        Suicides: none reported

·        Psychiatric diagnoses/hospitalization: mother MDD

·        Developmental diagnoses: none

 

 

Social History:

Occupational history: Employed full-time as a graphic designer.

Military service history: Denies prior military service.

Education history: Completed high school and vocational training.

Developmental history: No significant developmental concerns reported.

Legal history: No known legal issues NU675: Unit 3: Assignment Clinical SOAP Note.

Spiritual/Cultural considerations: None reported.

 

ROS:

Constitutional: Denies fevers, chills, or unintentional weight changes.

Eyes: Reports no vision changes or eye pain.

ENT: No hearing difficulties, sore throat, or swallowing problems.

Cardiovascular: Denies chest discomfort, palpitations, or swelling in extremities.

Respiratory: No shortness of breath, cough, or wheezing.

Gastrointestinal: Denies abdominal pain, nausea, vomiting, or changes in bowel habits.

Genitourinary: No dysuria, hematuria, or urinary frequency reported.

Musculoskeletal: No joint pain, stiffness, or muscle weakness.

Skin: Denies rashes, lesions, or other skin changes.

Neurological: No headaches, dizziness, seizures, or numbness/tingling.

Endocrine: No polyuria, polydipsia, or heat/cold intolerance.

Hematologic: Denies easy bruising, bleeding, or clotting problems.

Allergic/Immunologic: No allergic reactions, hives, or immune concerns.

Reproductive: Denies gynecologic issues such as abnormal menses, pregnancies, or miscarriages.

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°F

BP: 122/78 mmHg

HR: 72 bpm

R: 14/min

O2: 99% RA

Pain: 0/10

Ht: 5’5”

Wt: 154 lbs

BMI: 25.6

BMI Range: Overweight:

 

LABS:

Lab findings WNL

Thyroid Function (6 mo ago): TSH 2.1 mIU/L WNL

Tox Screen: Negative

Alcohol: Negative

HCG: N/A

 

Physical Exam:

General: Alert, cooperative, no distress

HEENT: Normocephalic, atraumatic; PERRLA; moist mucous membranes

Cardiovascular: RRR, no murmurs/rubs/gallops

Respiratory: Clear bilaterally

Abdomen: Soft, non-tender, non-distended

Neurologic: CN II-XII intact; motor 5/5; sensation intact; gait steady

MSE:

Patient is cooperative and communicative, appears without acute distress, and fully oriented to person, place, time, and situation. Patient is dressed neatly and appropriately for age and season. Psychomotor activity is within normal limits.

Presents with appropriate eye contact, affect is restricted but congruent with her reported mood of “tired and flat.” Speech is spontaneous, of normal rate, rhythm, and volume, with no difficulty expressing herself. Thought content is appropriate, with no delusions, obsessions, or perceptual disturbances. Denies suicidal or homicidal ideation. Thought process is linear, coherent, and goal-directed NU675: Unit 3: Assignment Clinical SOAP Note.

Cognition appears grossly intact, with alertness, intact memory, and mild impairment in concentration noted on serial sevens. Attention span is appropriate, and fund of knowledge is average. Judgment and insight are good.

The patient is able to articulate her needs, demonstrates motivation for adherence to her medication regimen, and is willing and able to participate actively in her treatment plan, including follow-up and self-monitoring of symptoms.

Diagnostic Data/Assessment Tools:

PHQ-9: 14 (moderate depressive severity)

GAD-7: 8 (mild anxiety severity)

 

 

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: –    F32.1 Major Depressive Disorder, recurrent episode, moderate severity

S.G. meets DSM-5-TR criteria for a recurrent major depressive episode, characterized by persistent insomnia, anhedonia, low energy, and impaired concentration for over two months, causing significant social and occupational impairment (APA, 2022).

Dx: –   F41.1 Generalized Anxiety Disorder, well-controlled

S.G.’s reduction in her GAD-7 score from a previously documented 15 to the current 8, along with her subjective report of decreased worry and absence of panic attacks, meets the clinical threshold for a “treatment response” (Szuhany & Simon, 2022).

Dx: –    G47.00 Insomnia Disorder:

Highly likely as a comorbid condition, though it is currently conceptualized as a core symptom of her active MDD.

Dx: –    E03.9 Hypothyroidism, stable

Stable under levothyroxine, TSH WNL

Patient demonstrates the capacity to understand and respond to information regarding psychiatric medications and psychotherapy. She appears to comprehend the purpose, potential benefits, risks, and alternatives, including the option to decline treatment, and expresses willingness to adhere to the agreed treatment plan.

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: N/A

 

Safety Risk/Plan:  Patient stable, minimal risk to self/others, no abnormal perceptions.

 

Pharmacologic interventions:

·        Escitalopram increased to 15 mg PO daily ×4 weeks; monitor side effects (Simon et al., 2024)

·        Trazodone 50 mg PO at bedtime PRN insomnia

Non-Pharmacologic Interventions:

·        CBT continuation

·        Sleep hygiene education

·        Encourage re-engagement in hobbies

·        Consider MBSR workshop referral if anxiety worsens

Education, including health promotion, maintenance, and psychosocial needs

·        Medication adherence

·        Sleep hygiene techniques

·        Psychosocial support, local depression groups

·        Safety planning and symptom monitoring

 

Referrals: Continue CBT therapist

Follow-up:

·        RTC in 4 weeks; complete PHQ-9/GAD-7 and sleep log

·        Call clinic for worsening symptoms, SI, or side effects

 

☒ > 50% time spent counseling/coordination of care: 35

 

Time spent in Psychotherapy 
20  
minutes

 

Visit lasted
70
minutes

 

Billing Codes for visit:   99214

F32.1 Major depressive disorder, recurrent, moderate

F41.1 Generalized Anxiety Disorder

G47.00 Insomnia, unspecified

E03.9 Hypothyroidism, unspecified

 

 

____________________________________________

NAME, TITLE

 

 

 

Date: Click here to enter a date.    Time: X

 

 

References

American Psychiatric Association. (2022).
Diagnostic and statistical manual of mental disorders
(5th ed., text rev.).
https://doi.org/10.1176/appi.books.9780890425787

Simon, G. E., Moise, N., & Mohr, D. C. (2024). Management of depression in adults.
JAMA, 332
(2), 141.
https://doi.org/10.1001/jama.2024.5756

Szuhany, K. L., & Simon, N. M. (2022). Anxiety disorders.
JAMA, 328
(24), 2431.
https://doi.org/10.1001/jama.2022.22744 
NU675: Unit 3: Assignment Clinical SOAP Note

 

NU675: Unit 3: Assignment Clinical SOAP Note

Clinical SOAP Note

Unit 3: Introduction (1 of 6)

Unit 3: Reading and Activities (2 of 6)

Unit 3: Discussion Complementary and Alternative Therapy (3 of 6)

Unit 3: Assignment Weekly Clinical Communication (4 of 6)

Current Assignment: Unit 3: Assignment Clinical SOAP Note (5 of 6)

Unit 3: Unit 3 Clinical Journal Reflection, Assignment (6 of 6)

Instructions

Each week students will choose one patient encounter to submit a Follow-up SOAP note for review.

Follow the rubric to develop your SOAP notes for this term.

The focus is on your ability to integrate your subjective and objective information gathering into the formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.

Note: Grades of Incomplete on this NU675: Unit 3: Assignment Clinical SOAP Note assignment will result in a clinical failure.

All work should be original and submitted as a Word document unless otherwise indicated in the assignment instructions. ALL assignments need to be APA 7 format and accompanied title page in APA 7th edition format in order that the work would be properly identified for the student, the course, and the assignment. Work submitted without a title page will receive a grade of 0.