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PMHNP Problem-Focused SOAP Note (Use this template for this Assignment) Demographic Data o Patient age and Patient’s gender identity o MUST BE HIPAA compliant. Subjective Chief Complaint (CC): o Place the patient’s CC complaint in Quotes History of Present Illness (HPI): o Reason for an appointment today. o The events that led to hospitalization or clinic visits today. o Include symptoms, relieving factors, and past compliance or non- compliance with medications o Any adverse effects from past medication use o Sleep patterns – number of hours of sleep per day, early wakefulness, not being able to initiate sleep, not able to stay asleep, etc. o Suicide or homicide thoughts present o Any self-care or Activity of Daily Living (ADL) such as eating, drinking liquids, self-care deficits or issues noted? o Presence/description of psychosis (if psychosis, command or non- command) Past Psychiatric History (PSH): o Past psychiatric diagnoses o Past hospitalizations o Past psychiatric medications use o Any non-compliance issues in the past? o Any meds that didn’t work for this patient? Family History of Psychiatric Conditions or Diagnoses: o Mother/father, siblings, grandparents, or direct relatives Social History: o Include nutrition, exercise, substance use (details of use), sexual history/preference, occupation (type), highest school achievement, financial problems, legal issues, children, history of personal abuse (including sexual, emotional, or physical). Allergies: o to medications, foods, chemicals, and other. Review of Systems (ROS) (Physical Complaints): o Any physical complaints by body system? (Respiratory, Cardiac, Renal, etc.) Objective Mental Status Exam: o This is not physical exam. o Mini-Mental Status Exam (MMSE) – Full exam Assessment (Diagnosis) Differentials o Two (2) differential diagnoses with ICD-10 codes. o Must include rationale using DSM-5 Criteria (Required) o Why didn’t you pick these as a major diagnosis?
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