you will choose one patient encounter to submit a Follow-up SOAP note for review.
Please see the Soap Note Template in Course Documents to guide your writing of SOAP notes.
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 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.
Psychiatry/Psychotherapy follow-up SOAP note TEMPLATE
***You will
replace all highlighted data
with information from a patient encounter from your weekly clinical visits. Add any additional information based on guidance from your clinical preceptor.
***You must use a new patient encounter for EVERY SOAP note that you tuen in throughout the program. NO DUPLICATION of SOAP Notes or PATIENT ENCOUNTERS is allowed. If this occurs it will be considered an
academic integrity issue.
Patient Name: XXX
MRN: XXX
Date of Service: 01-27-2020
Start Time: 10:00
End Time: 10:54
Billing Code(s): 90213, 90836
(Be sure to include strictly psychotherapy codes or both E&M and add on psychotherapy codes if prescribing provider visit)
Accompanied by: Brother
CC: Follow-up appt. for counseling
HPI: One week from inpatient care to current partial inpatient care daily individual psychotherapy session and extended daily group sessions
S- Patient states that he generally has been doing well with depressive and anxiety symptoms improved but he still feels down at times. He states he is sleeping better, achieving 7-8 hours of restful sleep each night. He states he feels the medication is helping somewhat and without any noticeable side-effects.
Crisis Issues: He states he has no suicide plan and has not thought about suicide since the recent attempt. He states has no access to prescription medications, other than the fluoxetine. He believes the classes he participated in while inpatient have helped him with coping mechanisms.
Reviewed Allergies: NKA
Current Medications: Fluoxetine 10mg daily
ROS: no complaints
O-
Vitals: T 98.4, P 82, R 16, BP 122/78
PE: (not always required and performed, especially in psychotherapy only visits)
Heart- RRR, no murmurs, no gallops
Lungs- CTA bilaterally
Skin- no lesions or rashes
Labs: CBC, lytes, and TSH all within normal limits
Results of any Psychiatric Clinical Tests: BAI=34
MSE:
Gary Davis, a 36-year-old white male, was disheveled and unkempt on presentation to the outpatient office. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age. During the interview, he was attentive and calm. He was impatient, but polite in his interactions with this examiner. Mr. Davis reported tha
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