10 Examples of SOAP Notes:
SOAP NOTE #1
Chief Complaint: : “Since I witnessed the fatal accident that claimed the lives of my close friends, I have been having recurring memories of that day even when sleeping”
Pt is an unemployed college student with no children. He lives in an apartment provided by parents in Los Angeles California.
History of Present Illness
The patient is a 27-year-old Caucasian man who appeared to f/u therapy weekly appt. with several complaints resulting from an incident he witnessed. The patient explained that he has been having recurrent and distressing memories of an accident that claimed three of his classmates as they were walking from evening classes. He also reports that he has continued to having upsetting dreams and nightmares about the accident. He has not been going to college through the route where the accident had occurred because something tells him that he will get involved in a similar accident too. Whenever he is watching TV and an incident covering an accident is aired, he develops severe emotional distress. He explains that he has still been having trouble sleeping, concentrating and gets irritated easily. The patient has resulted in taking alcohol, which he claims relieves some of the severe symptoms he is experiencing. The patient has been taking Prazosin 1mg orally at bedtime for one week, to reduce nightmares and sleep disturbances for one week., and reduced ability to sleep (6-7hours). No suicidal or homicidal thoughts.Denies history of, mood swings, cycling, and psychotic features. 10 Examples of SOAP Notes
Psychiatric History
PTSD since accident in 2020. Denies psychiatric hospitalizations.
Family History
Raised by biological mother and father. He is the only child, reports a good relationship with both parents.
Mother: Alive: No Hx
Father: Alive: No Hx
Alcohol/Substance Abuse/ Dependence (History and Current)
Denies use of drugs, and/or tobacco use. Pt admits to EToh use twice a week
Medical History
Denies History
Medications/Herbal/OTC:
Hx of Paxil x1 year Pt states ” I did not like how the med made me feell”
Prazosin 1mg po 1/21/21
Allergies
None
Mental Status Exam/Cognitive History
Orientated to time, place, person and situation.
Presents in an anxious mood.
Motor activity is calm.
Speech is soft, volume regular, coherent and spontaneous.
Intellectual functioning is unimpaired.
Eye contact is normal.
Cognitive fund of knowledge is average and age appropriate.
Body posture and attitude convey an underlying depressed mood.
Facial expression and general normal.
Associations are intact and reasonable.
There are no apparent signs of bizarre behaviors, hallucinations, delusions, or other markers of psychotic behaviors.
Associations are intact, thinking is logical, and thought content appears appropriate.
Denies suicidal ideas or intentions are denied.
Denies homicidal ideas or intentions are denied.
Cognitive functioning and fund of knowledge are intact and age appropriate.
Long term as well as short term memory are intact, as is ability to abstract and do arithmetic calculations. Vocabulary and fund of knowledge indicate cognitive functioning in the normal range.
Insight into problems appears fair.
Judgment appears fair.
MMSE is 29/30.
Hamilton Anxiety Scale (HAM-A):
Score 18
Substance History an assessment tool
Indicates low risk
Suicidal Behaviors Questionnaire (SBQ-R)
2 Indicates low risk
Problem List:
309.81 (F43.10) Post Traumatic Stress Disorder
Treatment Plan
- Pt will continue Prazosin 1mg po qhs.
- Direct exposure therapy: the patient will be taken through exposure therapy to help build his coping skills and integrate real-life exposures to feared situations in a safe and step by step method. Pt will continue cognitive processing therapy: the patient will be allowed to talk about the traumatic event and how the thoughts related to it have affected his life. Through this approach, the patient will be able to examine how he thinks about the event and figure out ways of living with it. Pt reminded that Prazosin 1mg orally can take up to a few weeks to work. 10 Examples of SOAP Notes
- Reinforcement of verbal and written education on ptsd and medication was provided. Pt encouraged not to use EToh.
- Risk and benefits Alternative to medication discussed.
- Pt is accepting of treatment and has verbalized understanding.
- Safety plan discussed.
- Pt acknowledged understanding of emergency resources such as going to ER or dialing 911if experiencing suicidal/homicide ideation.
- Will return in one week or as needed for a follow up on medication regimen, assess for suicidality and side effects.
SOAP NOTE #2
SUBJECTIVE:
CHIEF COMPLAINT: “Since my scholarship was withdrawn due to poor performance four months ago, things have never been the same again”
The patient is a 23-year-old young lady who is pursuing her associate degree in community college, presenting for follow up medication and initial therapy session. Pt c/o difficulty sleeping (3-5hours). No longer has decresed appetite (pt eating 2 meals/day) or tearfulness throughout the day every day. No longer feeling worse during the evening. Reports she is occasionally able to complete everyday activities such as going to the market without feeling fearful or anxious. Pt feels her medication is helping but still able to sleep. ” During therapy pt reports she has a poor background where fees to cater for her education could not be afforded. When she completed high school, she managed to get a scholarship under the condition that she will be performing well. However, in her second year of study things became tough and began to perform poorly. After several warnings, the scholarship was withdrawn and forced to drop school. From that moment, she explains that her life has changed. She has been experiencing occasional mood and emotional fluctuations such as anger and feelings of hopelessness. Denies si/hi.
Psychiatric History
Denies hospitalization. Hx of MDD diagnosed in 3/2020 Pt has not attended therapy. She’s been on Lexapro po 10 mg daily and trazadone po 25mg qhs for 3 months.
Family History
Lives with her Mother. No siblings or children. She has a good relationship with Mother.
Father Unknown
Denies family history of mental illness.
Alcohol/Substance Abuse/ Dependence (History and Current)
Denies drug, alcohol and tobacco use.
Medical History
COVID pos on Dec 2020
COVID neg on Jan 2021
Medications/Herbal/OTC:
Lexapro po 10 mg daily
trazadone po 25mg qhs
Allergies
NKA
Problem List:
296.32 (F33.1) -Major depressive disorder, recurrent, moderate
WT: 124 Lbs.
HT: 5ft 4”
BMI: 20
Mental/Functional:
Normal
Mental Status Exam:
Appearance: Attire was appropriate, good hygiene
Behavior: cooperative
Speech: slow
Eye contact: avoidant
Attention span: distracted
Mood: anxious, tearful
Affect: sad
Thought content: Denies si/hi/hallucinations or delusions
Thought process: linear
Motor: normal
Good insight, cooperative and good judgement
Orientation: Oriented to person, place, time, event/s
Treatment Plan
- Prescription for Lexapro po 20mg daily and trazadone 50 mg po qhs.
- Patient is continuing CBT therapy outpatient weekly at this time. . CBT helps to address overstimulation and self-sabotaging behaviors by replacing negative thoughts with evidenced based thinking. Behavioral practice includes exposure to anxiety provoking situation to reduce constant worry and in turn change emotional response to the anxiety. 10 Examples of SOAP Notes
- Reinforcement of verbal and written education on depression and medication was provided. •Risk and benefits Alternative to medication discussed.
- Pt is accepting of treatment and has verbalized understanding.
- Safety plan discussed.
- Pt acknowledged understanding of emergency resources such as going to ER or dialing 911if experiencing suicidal/homicide ideation.
- Will return to clinic in one month or as needed for a follow up on medication regimen, assess for suicidality and side effects.
PLAN: Referral to a psychotherapist for psychotherapy. Through psychotherapy, the patient will be helped to know the cause of her symptoms, feel more in control and get to know the ways to handle her condition to feel better. The idea behind this type of therapy will be to enable her to track her moods and practice new ways of coping with the current situation. 10 Examples of SOAP Notes
SOAP NOTE #3
SUBJECTIVE
Chief complaint: “My son has developed peculiar behavior in the last one month. At times he comes to our house running claiming that he has heard people murmuring around her house who want to kill him”
Pt is an unemployed high school student recovering from drug abuse. He has been transferred from his initial school by his mother to avoid bad company
History of Present Illness
Joel is an 18-year-old young man who was presented to our clinic by his mother. The mother claims that the son had developed some peculiar behaviors in the last month. According to the mother, the son has been claiming to hear people around her house murmuring. He claimed that the people were his former schoolmates who wanted to kill him because he reported them to the police. According to the mother, Joel had been taking drugs with his friends in his former school but when she realized, she reported them to the police and later transferred Joel to a different school. When we tried to interview Joel, we realized that his speech was disorganized and could not answer the questions we asked him systematically. Sometimes, he could give unrelated answers. Also, he had an extremely disorganized behavior. Although a grown-up, Joel still displayed childlike silliness and unpredictable agitation. The mother explained that Joel was performing well in his former school and related well with friends but he has lately withdrawn from friends and his performance dropped.
Psychiatric History
Social Anxiety when he was 11 years old. Denies psychiatric hospitalization
Family History
Raised in a single parent family. He is the first born in the family of two. He has a good relationship with his mother
Mother: Alive: No Hx
Alcohol/Substance Abuse/ Dependence (History and Current)
He has been drinking alcohol and smoking Marijuana
Medical History
Denies History
Medications/Herbal/OTC:
Lamictal 50mg QD, Clozapine 150mg QD 150mg @HS
Allergies
None
Mental Status Exam/Cognitive History
Presents in an anxious mood
Body posture and attitude convey an underlying condition
Denies suicidal ideas or intentions are denied.
Denies homicidal ideas or intentions are denied.
Hamilton Anxiety Scale (HAM-A):
Score 18
Substance History an assessment tool
Indicates high risk
Suicidal Behaviors Questionnaire (SBQ-R)
2 Indicates low risk
Problem List:
99483 (F12.13) Schizophrenia
Treatment Plan:
Pt Continue with Lamictal 50 mg QD increase dose of Clozapin 150mg BID to 150mg in the morning and 200mg @HS, schedule follow/up apt after 2 weeks
Group therapy. The group therapy will help him and his family feels less alone. Through the interaction with other group members, Joel will get emotional support, acceptance and advice. By speaking to other schizophrenics about his symptoms and participating in the dialogue about his condition, Joel will be able to see his problems in the experience of others. 10 Examples of SOAP Notes
Risk and benefits Alternative to medication discussed.
Will return in two weeks time or as needed for a follow up on medication regimen, assess for suicidality and side effects.
SOAP NOTE #4
SUBJECTIVE
Chief complaint: “I have been experiencing peculiar mood fluctuations that highly interfere with my normal routine”
Pt is an employed middle aged woman with two children. She is married to a drug addict and works as a clerk in an accounting firm
History of Illness
Jane a 32-year-old African American woman appeared at the clinic with complaints about her moods. She explains that her moods have been fluctuating peculiarly. According to her explanation, she sometimes experiences severe high moods that makes her super active. At these moments, she is highly productive. However, the high moods are followed closely by very low moods that change everything, right from how she sleeps, thinks and behaves. Her major issue is the low moods because she barely performs during those times. As a result of her low moods, she has been warned severally at her workplace and fears that she might lose her job because of the condition. 10 Examples of SOAP Notes
Psychiatric History
Depression at the age of 21. Denies psychiatric hospitalization
Family History
Married to a drug addict. He relates well with his two children. The husband is abusive and irresponsible
Vitals
BP: 130/84
HR: 81
RR: 18
Alcohol/Substance Abuse/ Dependence (History and Current)
Denies use of drugs, and/or tobacco use. Pt admits to EToh use twice a week
Medical History
Denies History
Medications/Herbal/OTC:
None
Allergies
None
Mental Status Exam/Cognitive History
Orientated to time, place, person and situation.
Presents in an anxious mood.
Motor activity is calm
Eye contact is normal.
Cognitive fund of knowledge is average and age appropriate.
Body posture and attitude convey an underlying depressed mood
Denies suicidal ideas or intentions are denied.
Denies homicidal ideas or intentions are denied.
Cognitive functioning and fund of knowledge are intact and age appropriate
Insight into problems appears fair
Hamilton Anxiety Scale (HAM-A):
Score 17
Substance History an assessment tool
Indicates low risk
Suicidal Behaviors Questionnaire (SBQ-R)
2 Indicates low risk
Problem List:
99483 (F07.9) Bipolar Disorder
Treatment Plan
Prescription of Carbamazepine 200mg orally twice a day
Referral for an Interpersonal and Social Rhythm Therapy (IPSRT) for purposes of stabilizing the circadian rhythm disruptions experienced by the patient.
Risk and benefits Alternative to medication discussed.
- Pt is accepting of treatment and has verbalized understanding.
- Safety plan discussed.
Will return after three weeks or as needed for a follow up on medication regimen, assess for suicidality and side effects.
SOAP NOTE #5
SUBJECTIVE
Chief complaint: “There is a peculiar fear that has engulfed me lately; I cannot cross a bridge unless someone holds my hand. Also, I cannot ride my car on a highway as I used to do. What could be the problem? ”
Pt is a single mother of two working as a chef in an international hotel. She has been exercising regularly to control her body weight
History of Illness
The patient is a 30-year-old African American woman who visited the health facility with a complaint about a peculiar fear that she was experiencing lately. She narrated how the fear has interfered with some of her daily activities such as riding her car to work and doing morning exercises. She explained that she has been experiencing extreme fear when she tries to ride on the highway. Because of that fear, she has resulted to using public means of transport that makes her report late to work. She is also afraid to cross long bridges and unless someone holds her hand she cannot cross a bridge. She explained that the fear has engulfed her a few months ago. She has a medical history of a panic attack which she is still undergoing medication. She has a family history of depression, which affected her late father and brother. 10 Examples of SOAP Notes
Psychiatric History
None. Denies psychiatric hospitalizations.
Family History
Pt is a single mother of two. Her nhusband died five years ago following a road accident. She relates well with her two children
Alcohol/Substance Abuse/ Dependence (History and Current)
Denies use of drugs, and/or tobacco use.
Medical History
Insulin to control her diabetic condition
Medications/Herbal/OTC:
Fluoxetine 20mg orally once a day and Serotonin 50mg three times a day.
Allergies
None
Mental Status Exam/Cognitive History
Orientated to time, place, person and situation
Speech is soft, volume regular, coherent and spontaneous.
Intellectual functioning is unimpaired.
Eye contact is normal.
Cognitive fund of knowledge is average and age appropriate.
Associations are intact, thinking is logical, and thought content appears appropriate.
Denies suicidal ideas or intentions are denied.
Denies homicidal ideas or intentions are denied.
Cognitive functioning and fund of knowledge are intact and age appropriate.
Long term as well as short term memory are intact
Hamilton Anxiety Scale (HAM-A):
Score 18
Substance History an assessment tool
Indicates low risk
Suicidal Behaviors Questionnaire (SBQ-R)
2 Indicates low risk
Problem List:
99483 (F09) Agoraphobia
Treatment Plan:
Increase script for Fluoxetine 20mg BID to 50mg BID, Serotonin 50mg BID to 100mg
Risk and benefits Alternative to medication discussed.
Pt is accepting of treatment and has verbalized understanding.
Safety plan discussed.
Schedule a follow up appointment in the next 3 weeks.
Referral for Cognitive Behavioral Therapy to help modify her negative thoughts, emotions and responses associated with psychological distress.
SOAP NOTE #6
SUBJECTIVE
Chief complaint: “Follow up after depression”
Pt is an unemployed student with no children. She is living with her parents in an apartment in Los Angeles California
History of Illness
Cate, a 22-year-old Hispanic female came to our health facility to follow up on her depression condition. It is now 5 months since she last visited our health facility, was diagnosed with depressive symptoms at an initial stage and was prescribed medication to control her condition. Some of the prescribed medication includes Aripiprazole 15mg orally once a day, Citalopram 20mg orally once a day and Sertraline 50mg orally once a day. Cate explained that her condition continued to improve for the next four months. However, things changed in the last month and the symptoms started to recur. She explains that she has been experiencing uncontrolled emotions, loss of interest in almost everything, increased fatigue and lack of sleep. 10 Examples of SOAP Notes
Psychiatric History
Depressiom since accident in 2019. Denies psychiatric hospitalizations.
Family History
Raised by biological mother and father. He is the only child, reports a good relationship with both parents.
Mother: Alive: No Hx
Father: Alive: No Hx
Alcohol/Substance Abuse/ Dependence (History and Current)
Denies use of drugs, and/or tobacco use
Medical History
Denies History
Medications/Herbal/OTC:
Aripiprazole 15mg orally once a day, Citalopram 20mg orally once a day and Sertraline 50mg orally once a day
Vitals
BMI: 35
BP: 128/78
P: 69
RR: 16
Allergies
None
Mental Status Exam/Cognitive History
Orientated to time, place, person and situation.
Presents in an anxious mood.
Motor activity is calm.
Speech is soft, volume regular, coherent and spontaneous.
Cognitive fund of knowledge is average and age appropriate.
Body posture and attitude convey an underlying depressed mood.
Facial expression and general normal.
Denies suicidal ideas or intentions are denied.
Denies homicidal ideas or intentions are denied.
Cognitive functioning and fund of knowledge are intact and age appropriate
Hamilton Anxiety Scale (HAM-A):
Score 17
Substance History an assessment tool
Indicates low risk
Suicidal Behaviors Questionnaire (SBQ-R)
2 Indicates low risk
Problem List:
99483 (F06.32)Depression (Contractor et al., 2017)
Treatment Plan
Increase script for Aripiprazole 15mg BID to 20mg BID and make a follow up appointment for 2 weeks
Risk and benefits Alternative to medication discussed.
Pt is accepting of treatment and has verbalized understanding.
Additional treatment: Lexapro is 10 mg once daily
Referral: Psychotherapy
SOAP NOTE #7
SUBJECTIVE:
Chief complaint: “The attentiveness of my daughter is wanting; she is also hyperactive and impulsive”
Pt is a young girl in her teenage age. She has been raised by her mother alone since her father died following a road accident
History of Illness
Ann, a 13-year-old girl was brought to the health facility by her mother with complaints about the current behavior of the girl both at school and home. She narrated that the girl is easily distracted when doing her daily chores and school work. She has also been making careless mistakes which reflect absent-mindedness. According to the mother, the girl cannot stick to duties that seem tedious or time-consuming. She rarely listens to instructions and hence ends up doing things in her way. Ann rarely sits still, especially in calm and quiet environments. Due to this excessive physical movement, she has had a hand fracture two times. In school, teachers have complained that the girl is excessively talking; she rarely waits for her turn when doing things. She tends to interrupt conversations. Ann has a medical history of being both prematurely. The family has a history of Attention-Deficit/Hyperactivity Disorder (ADHD), a condition that has affected three of Ann’s paternal cousins. 10 Examples of SOAP Notes
Psychiatric History
None
Family History
Raised by biological mother. He is the only child, reports a good relationship with her mother.
Mother: Alive: No Hx
Father: Died: No Hx
Alcohol/Substance Abuse/ Dependence (History and Current)
Denies use of drugs, and/or tobacco use
Medical History
Denies History
Medications/Herbal/OTC:
Methylphenidate 20mg orally three times a day and Guanfacine 1mg once a day.
Allergies
None
Vitals
BMI: 23.4
BP: 120/78
P: 69
RR: 16
Mental Status Exam/Cognitive History
Intellectual functioning is impaired.
Motor activity is not calm
Presents in an anxious mood.
Cognitive functioning and fund of knowledge are intact and age is inappropriate.
Insight into problems appears poor.
Judgment appears poor.
Hamilton Anxiety Scale (HAM-A):
Score 10
Substance History an assessment tool
Indicates low risk
Suicidal Behaviors Questionnaire (SBQ-R)
2 Indicates low risk
Problem List:
99483 (F90.1) Attention-Deficit/Hyperactivity Disorder (ADHD) (Takeda et al., 2017)
Treatment Plan
Refill of Methylphenidate 20mg orally three times a day and Guanfacine 1mg once a day
An appointment after 3 weeks
Referral to a therapist for a Behavioral therapy
Risk and benefits Alternative to medication discussed.
Pt is accepting of treatment and has verbalized understanding.
Safety plan discussed.
SOAP NOTE #8
SUBJECTIVE
CHIEF COMPLAINT: “Medication feels like it is not working”
Pt is a single woman with no kids who appears to the clinic the second time to follow up on a condition that engulfed her after securing a new job in California.
History of Illness
Alexis is a 28-year-old single Asian woman with no kids who appeared at our clinic for a follow-up visit. She explained that she recently moved to California to start a new job. Being new in the city, she knew that the experience would be stressful because she will have to navigate around the city where she did not have friends. She explained that the experience was depressing and everything seemed to be falling apart. She lost her appetite leading to a loss of 15 pounds; her concentration was highly affected and felt tired all through. She knew that the anxiety of moving away from home was the cause of her problems, and began to seek treatment. She was diagnosed with a major depressive disorder (MDD) and was prescribed Aripiprazole 15mg orally once a day, Citalopram 20mg orally once a day. However, she reports that she had not experienced any changes in depressed moods, sleeping, concentration and eating habits. Therefore she feels that the medication is not working “medication feels like it is not working”. She denies hallucinations, delusions and suicidal thoughts. There is no history of mental illnesses in her family; her psychiatric history indicates that she faced depression at the age of 17 when she failed her high school exams. 10 Examples of SOAP Notes
Psychiatric History
Major Depressive Disorder (MDD)
Family History
Raised by biological mother and father in a family of four, reports a good relationship with both parents.
Mother: Alive: No Hx
Father: Alive: No Hx
Alcohol/Substance Abuse/ Dependence (History and Current)
Denies use of drugs, and/or tobacco use.
Medical History
Denies History
Medications/Herbal/OTC:
Aripiprazole 15mg orally once a day, Citalopram 20mg orally once a day
Allergies
None
Vitals
BP: 128/81
HR: 81
RR: 18
WT: 123 Lbs
HT: 5ft 4”
Mental Status Exam/Cognitive History
Orientated to time, place, person and situation.
Presents in an anxious mood.
Cognitive fund of knowledge is average and age appropriate.
Body posture and attitude convey an underlying depressed mood.
Facial expression and general normal.
Denies suicidal ideas or intentions are denied.
Denies homicidal ideas or intentions are denied.
Cognitive functioning and fund of knowledge are intact and age appropriate.
Hamilton Anxiety Scale (HAM-A):
Score 16
Substance History an assessment tool
Indicates low risk
Suicidal Behaviors Questionnaire (SBQ-R)
2 Indicates low risk
Problem List:
99483 (F09) Major depressive disorder (MDD) (Gaspersz et al., 2017)
Treatment Plan
Increase script of Aripiprazole 15mg to 20mg orally once a day, Citalopram 20mg to 50mg once a day
Risk and benefits Alternative to medication discussed.
Safety plan discussed.
Referral to a therapist for psychotherapy and integrative therapy
Appointment scheduled after 2 weeks for a follow up on medication
SOAP NOTE #9
SUBJECTIVE
CHIEF COMPLAINT: “I feel better now; the medication has worked miracles”
Pt is a single woman with no children. She is working as an assistant manager in a big organization. She returns for a follow up on her Generalized Anxiety Disorder condition
History of Illness
The patient is a 38-year-old single African American woman who returned to our clinic for a follow up on her condition, five weeks since she left the clinic citing feelings of frustration, anxious and overwhelmed when on her line of duty as an assistant manager. She was diagnosed with a generalized anxiety disorder and was prescribed Lexapro 10mg once daily and Paxil 20mg once a day. She was also referred to a therapist for Cognitive Behavioral Therapy (CBT). Today, she reports decreased muscular tension, increased appetite, and the ability to concentrate and sleep well. Her social life has highly improved and began dating. The patient is responding well to the treatment. The patient family history indicates that she does not have children and no history of mental illness. 10 Examples of SOAP Notes
Psychiatric History
Generalized Anxiety Disorder since accident in 2019. Denies psychiatric hospitalizations.
Family History
Raised by biological mother and father. He is the only child, reports a good relationship with both parents.
Mother: Alive: No Hx
Father: Alive: No Hx
Alcohol/Substance Abuse/ Dependence (History and Current)
Denies use of drugs, and/or tobacco use. Pt admits to EToh use twice a week
Medical History
Denies History
Medications/Herbal/OTC:
Lexapro 10mg once daily and Paxil 20mg once a day
Therapy session every week
Allergies
None
Mental Status Exam/Cognitive History
Orientated to time, place, person and situation.
Presents in an anxious mood.
Motor activity is calm.
Speech is soft, volume regular, coherent and spontaneous. 10 Examples of SOAP Notes
Intellectual functioning is impaired.
Eye contact is normal.
Cognitive fund of knowledge is average and age appropriate.
Body posture and attitude convey an underlying depressed mood.
Facial expression and general normal.
Associations are intact and reasonable.
There are no apparent signs of bizarre behaviors, hallucinations, delusions, or other markers of psychotic behaviors.
Associations are intact, thinking is logical, and thought content appears appropriate.
Denies suicidal ideas or intentions are denied.
Denies homicidal ideas or intentions are denied.
Cognitive functioning and fund of knowledge are intact and age appropriate.
Long term as well as short term memory are intact
Hamilton Anxiety Scale (HAM-A):
Score 18
Substance History an assessment tool
Indicates low risk
Suicidal Behaviors Questionnaire (SBQ-R)
2 Indicates low risk
Problem List:
99483 (F41.1) Generalized Anxiety Disorder (Price et al., 2019)
Treatment Plan
Continue taking Lexapro 10mg once daily and Paxil 20mg once a day
Continue attending therapy sessions until she finishes the whole session.
Risk and benefits Alternative to medication discussed.
Pt is accepting of treatment and has verbalized understanding.
Safety plan discussed.
Appointment scheduled after three weeks for a follow up on medication and any side effects.
SOAP NOTE #10
SUBJECTIVE
Chief complaint: “I am adhering to the medication prescribed but it is not working”
Pt is a widowed woman who is taking care of her three children. She is a housewife but has been looking for a job opportunity since her husband died
History of Illness
Amy is a 33-year-old widowed Hispanic woman, a housewife with three children, two boys and one girl. She first came to the clinic three weeks ago complaining of continuous trembling, fatigue, restlessness, irritability and difficulties when concentrating. She was diagnosed with a depressive condition following the death of her husband. She has been prescribed Fluvoxamine 50mg orally once a day and serotonin 50mg three times a day. She was also referred to a therapist for a psychotherapy session. However, today she appeared with the complaint that nothing seems to be working despite adhering strictly to the medication and therapy sessions. Amy’s psychiatric history indicates that she was diagnosed with depression three weeks ago and has been attending psychotherapy sessions, and taking Fluvoxamine 50mg orally once a day and serotonin 50mg three times a day. The family history shows that Amy is living with her mother in law together with children since her husband passed. The social history shows that Amy is the unemployed bus has been looking for a job since her husband who was the sole breadwinner in the family passed. Amy does not take alcohol. 10 Examples of SOAP Notes
Psychiatric History
Depression. Denies psychiatric hospitalizations.
Family History
Pt is a widow who is raising her children alone following the death of her husband. The family does not have a breadwinner
Alcohol/Substance Abuse/ Dependence (History and Current)
Denies use of drugs, and/or tobacco use. Pt admits to EToh use twice a week
Medical History
Denies History
Medications/Herbal/OTC:
Fluvoxamine 50mg orally once a day
Serotonin 50mg three times a day
Allergies
None
Mental Status Exam/Cognitive History
Body posture and attitude convey an underlying depressed mood.
Speech is soft, volume regular, coherent and spontaneous.
Intellectual functioning is impaired.
Associations are intact, thinking is logical, and thought content appears appropriate.
Denies suicidal ideas or intentions are denied.
Denies homicidal ideas or intentions are denied.
Cognitive functioning and fund of knowledge are intact and age appropriate.
Hamilton Anxiety Scale (HAM-A):
Score 18
Substance History an assessment tool
Indicates low risk
Suicidal Behaviors Questionnaire (SBQ-R)
2 Indicates low risk
Problem List:
99483 (F06.8) Depression (Tolentino & Schmidt, 2018)
Treatment Plan
Increase script of Fluvoxamine 50mg to 100mg orally once a day
Serotonin 50mg to 100mg three times a day
Proposed change of therapist and continue with psychotherapy.
Appointment scheduled after three weeks for a further follow up of her condition.
References
Carmassi, C., Bertelloni, C. A., Cordone, A., Cappelli, A., Massimetti, E., Dell’Oste, V., & Dell’Osso, L. (2020). Exploring mood symptoms overlap in PTSD diagnosis: ICD-11 and DSM-5 criteria compared in a sample of subjects with Bipolar Disorder. Journal of Affective Disorders, 276, 205-211.
Contractor, A. A., Roley-Roberts, M. E., Lagdon, S., & Armour, C. (2017). Heterogeneity in patterns of DSM-5 posttraumatic stress disorder and depression symptoms: latent profile analyses. Journal of Affective Disorders, 212, 17-24.
Dunn, E. C., Nishimi, K., Powers, A., & Bradley, B. (2017). Is developmental timing of trauma exposure associated with depressive and post-traumatic stress disorder symptoms in adulthood?. Journal of psychiatric research, 84, 119-127.
Fusar-Poli, P., De Micheli, A., Cappucciati, M., Rutigliano, G., Davies, C., Ramella-Cravaro, V., … & McGuire, P. (2018). Diagnostic and prognostic significance of DSM-5 attenuated psychosis syndrome in services for individuals at ultra high risk for psychosis. Schizophrenia bulletin, 44(2), 264-275.
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