SOAP Note Template for Psychiatry

.soap

Subjective
– Chief Complaint:

Patient’s statement about their main issue

– History of Present Illness (HPI):

[Description of current symptoms, onset, duration, and severit

– Review of Systems (Psych):

Patient’s description of psychiatric symptoms

– Patient’s Perception:

Patient’s understanding and beliefs regarding their illness

Objective
– Vital Signs:

BP, HR, Temperature, etc., if relevant

– Mental Status Examination (MSE):

Objective findings during the visit

– Physical Examination:

Relevant findings, if any

Assessment
– Diagnosis:

Diagnosis or differential diagnoses, with DSM codes if applicable

– Progress:

Comparison with previous status or baseline

– Risk Factors:

Any risk factors for violence, self-harm, or non-compliance

Plan
– Medications:

List changes, additions, or continuations

– Psychotherapy:

Type, focus, frequency of sessions

– Education:

Information provided to the patient about their condition

– Follow-Up:

Timing and specific goals for next visit

– Referrals:

Referrals to other services or specialists, if needed

– Safety Planning:

Any arrangements made considering risk assessment

Add to TextExpander