Initial Psychiatric SOAP Note Template
There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective,
Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to
develop your style of SOAP in the psychiatric practice setting.
Criteria Clinical Notes
Informed Consent Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy
treatment. Verbal and Written consent obtained. Patient the ability/capacity to
respond and appears to the risk, benefits, and (Will review additional consent during
treatment plan discussion)
Subjective Verify Patient. Verified by Two forms
Verify Patient: Name, Name: Jane Doe
Assigned identificati DOB: 07/25/1972
on number (e.g.,
medical record
number), Date of Accompanied by: Self
birth, Phone number,
Social security Demographic: African American
number, Address,
Photo.
Gender Identifier Note: Female
Include
CC: Anxiety Related to multiple health problems
demographics, chief
complaint, subjective
HPI: During her current visit to the clinic, Jane, 51, complains of extreme agitation, tiredness,
information from the
and pain in the chest with constant worries. In addition, the patient expresses concern about her
patient, names and
relations of others
health on a frequent basis. Her worries have interfered with her ability to function with daily
present in the life, and she feels that she can't be left alone without someone to reassure her. Despite the fact
interview. that the intensity of these problems has varied over the years, it has gotten worse over the last
three months since her husband's heart condition developed. Her favorite way to calm herself
HPI: down is to drink wine each night. She is afraid of being left alone as she may harm herself.
While Jane has her family's support, they are no longer able to manage the situation because of
Jane's illness. Anxiety and suicidal ideation have increased in the patient, and there is a danger
of suicide. In order to complete her suicide, Jane has a plan, intention, and means.
Approximately four years ago, the patient received counseling at Montgomery Recovery
Services that was helpful to her. The patient has also attended individual guided self-help but
, Past Medical and
says it didn't help. Additionally, Jane was referred to a self-help group for people with anxiety
Psychiatric History,
Current Medications, at the Hope House, but she did not attend. Furthermore, the patient reports a prior suicide
Previous Psych Med attempt when she was 28 years old, when she took an overdose following the breakup of a
trials, relationship when she was 28 years old.
, Allergies. Pertinent history in record and from patient: Pt reported having a history of diabetes, hypertension, and
cardiovascular arteriosclerosis.
Social History, Family
History. During assessment: Patient describes their mood as calm during the session. Certain questions make her
Review of Systems defensive.
(ROS) – if ROS is
negative, “ROS Patient self-esteem appears There are no reported feelings of excessive guilt, no reported anhedonia, no
reported sleep disturbances, no reported changes in appetite, no reported changes in libido, no reported
noncontributory,” or changes in energy, no reported changes in concentration.
“ROS negative with
the exception of…” Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria.
Patient does not report excessive fears, worries or panic attacks.
Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity level,
attention and concentration were observed to be within normal limits. Patient does not report symptoms of
eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a
characterological nature.
SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent
behavior, denies inappropriate/illegal behaviors. Though admits to an attempted SI when she was 28 years
old
Allergies: NKDFA.
(medication & food)
Past Medical Hx:
Medical history: Pt reported having a history of diabetes, hypertension, and cardiovascular arteriosclerosis.
Nutritional status (this is an important component to gauge how well the mind and body are being nourished
for full function. Ex: lack of iodine create thyroid issues, thyroid issues creates metabolism issues which
affects function of cognition, mood, etc…)
Past Psychiatric Hx:
Previous psychiatric diagnoses: Anxiety Disorder
Describes course of illness.
Previous medication trials: Vistaril 25 mg PO.
Safety concerns:
History of Violence to Self: Attempted SI at age 28 years old following a breakup
History of Violence to Others: none reported
Auditory Hallucinations: None reported.
Visual Hallucinations: None reported.
Mental health treatment history discussed: Counseling at Montgomery Recovery Services.
History of outpatient treatment: Counseling and Self-help Group at Montgomery Recovery Services
Previous psychiatric hospitalizations: None reported.
Prior substance abuse treatment: None reported.
Trauma history: Client does not report history of trauma including abuse, domestic violence, witnessing
There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective,
Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to
develop your style of SOAP in the psychiatric practice setting.
Criteria Clinical Notes
Informed Consent Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy
treatment. Verbal and Written consent obtained. Patient the ability/capacity to
respond and appears to the risk, benefits, and (Will review additional consent during
treatment plan discussion)
Subjective Verify Patient. Verified by Two forms
Verify Patient: Name, Name: Jane Doe
Assigned identificati DOB: 07/25/1972
on number (e.g.,
medical record
number), Date of Accompanied by: Self
birth, Phone number,
Social security Demographic: African American
number, Address,
Photo.
Gender Identifier Note: Female
Include
CC: Anxiety Related to multiple health problems
demographics, chief
complaint, subjective
HPI: During her current visit to the clinic, Jane, 51, complains of extreme agitation, tiredness,
information from the
and pain in the chest with constant worries. In addition, the patient expresses concern about her
patient, names and
relations of others
health on a frequent basis. Her worries have interfered with her ability to function with daily
present in the life, and she feels that she can't be left alone without someone to reassure her. Despite the fact
interview. that the intensity of these problems has varied over the years, it has gotten worse over the last
three months since her husband's heart condition developed. Her favorite way to calm herself
HPI: down is to drink wine each night. She is afraid of being left alone as she may harm herself.
While Jane has her family's support, they are no longer able to manage the situation because of
Jane's illness. Anxiety and suicidal ideation have increased in the patient, and there is a danger
of suicide. In order to complete her suicide, Jane has a plan, intention, and means.
Approximately four years ago, the patient received counseling at Montgomery Recovery
Services that was helpful to her. The patient has also attended individual guided self-help but
, Past Medical and
says it didn't help. Additionally, Jane was referred to a self-help group for people with anxiety
Psychiatric History,
Current Medications, at the Hope House, but she did not attend. Furthermore, the patient reports a prior suicide
Previous Psych Med attempt when she was 28 years old, when she took an overdose following the breakup of a
trials, relationship when she was 28 years old.
, Allergies. Pertinent history in record and from patient: Pt reported having a history of diabetes, hypertension, and
cardiovascular arteriosclerosis.
Social History, Family
History. During assessment: Patient describes their mood as calm during the session. Certain questions make her
Review of Systems defensive.
(ROS) – if ROS is
negative, “ROS Patient self-esteem appears There are no reported feelings of excessive guilt, no reported anhedonia, no
reported sleep disturbances, no reported changes in appetite, no reported changes in libido, no reported
noncontributory,” or changes in energy, no reported changes in concentration.
“ROS negative with
the exception of…” Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria.
Patient does not report excessive fears, worries or panic attacks.
Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity level,
attention and concentration were observed to be within normal limits. Patient does not report symptoms of
eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a
characterological nature.
SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent
behavior, denies inappropriate/illegal behaviors. Though admits to an attempted SI when she was 28 years
old
Allergies: NKDFA.
(medication & food)
Past Medical Hx:
Medical history: Pt reported having a history of diabetes, hypertension, and cardiovascular arteriosclerosis.
Nutritional status (this is an important component to gauge how well the mind and body are being nourished
for full function. Ex: lack of iodine create thyroid issues, thyroid issues creates metabolism issues which
affects function of cognition, mood, etc…)
Past Psychiatric Hx:
Previous psychiatric diagnoses: Anxiety Disorder
Describes course of illness.
Previous medication trials: Vistaril 25 mg PO.
Safety concerns:
History of Violence to Self: Attempted SI at age 28 years old following a breakup
History of Violence to Others: none reported
Auditory Hallucinations: None reported.
Visual Hallucinations: None reported.
Mental health treatment history discussed: Counseling at Montgomery Recovery Services.
History of outpatient treatment: Counseling and Self-help Group at Montgomery Recovery Services
Previous psychiatric hospitalizations: None reported.
Prior substance abuse treatment: None reported.
Trauma history: Client does not report history of trauma including abuse, domestic violence, witnessing
