Psychiatric soap note

SOAP note serves as a structured method for a nurse practitioner to document a patient’s health information, including their subjective complaints, objective findings from the physical exam, their assessment (diagnosis), and the plan for treatment, allowing for clear communication and continuity of care with other healthcare providers involved in the patient’s case.

Key points about SOAP notes for nurse practitioners:

Standardized format:

SOAP stands for “Subjective, Objective, Assessment, and Plan,” providing a consistent framework for documenting patient encounters.

Comprehensive information: The subjective section captures the patient’s reported symptoms and history, while the objective section details physical exam findings, lab results, and vital signs.

Clinical reasoning:

The assessment section allows the nurse practitioner to synthesize the subjective and objective data to reach a diagnosis and differential diagnoses.

Treatment plan:

The plan section outlines the proposed interventions, medications, patient education, and follow-up appointments.

Communication tool:

SOAP notes facilitate clear communication between healthcare providers, ensuring everyone is on the same page regarding the patient’s condition and management plan. SOAP notes serve as a structured method for a nurse practitioner to document a patient’s health information, including their subjective complaints, objective findings from the physical exam, their assessment (diagnosis), and the plan for treatment, allowing for clear communication and continuity of care with other healthcare providers involved in the patient’s case.

SUBJECTIVE: Patient described in appropriate detail Concise and clear chief complaint as described by patient HPI includes all components with appropriate detail Comprehensive review of focus system(s) includes pertinent negatives Name, dose, route, and frequency of prescribed and overthecounter medications noted, including compliance; Allergies to medications and reaction noted Comprehensive health history is appropriate to reason for visit and includes pertinent negatives

OBJECTIVE: Physical exam includes appropriate areas for Chief Complaint, History of Presenting Illness, and Review of Systems…. Appropriate techniques of examination used to identify pertinent findings

ASSESSMENT: Three differential diagnoses are supported by findings and include worst case scenario Rationale for differential diagnoses provided by scholarly resources

PLAN: Comprehensive plan to address likely differential diagnosis includes

Diagnostic testing

Pharmacologic intervention

Nonpharmacologic intervention

Referrals

Patient education

Followup

Plan is supported by appropriate and current practice guidelines

Documentation follows SOAP template, is logical, and in correct format