Advanced Psychopharmacology

Psychiatric SOAP Note Presentation

Slide 1

Hi everyone. My name is Cassandra Godzik, nurse practitioner in the Regis College program. Today we are going to be talking about the psychiatric SOAP note and how the SOAP note looks differently compared to the medical SOAP know that you might have seen in practice. There are some major differences, and I want to be sure that we review and cover each component of the SOAP note so that you can know how to move forward with the documentation.

Slide 2

To get started, we are just going to cover what the psychiatric SOAP is, what it looks like, and then we are going to go into more detail about what it actually includes. Be sure to take a look at the psychiatric SOAP note template that also goes along with this presentation. It will help you when you are actually completing a SOAP note for a patient or a case study in the class.

Slide 3

What exactly is a psychiatric SOAP note? SOAP notes are used for documenting patient care - what we see, what the plan is- the treatment plan for our patients both in the medical setting and in the psychiatric setting. For both settings, the acronym is Subjective, Objective, Assessment, and Plan, and within each of those components you are going to document information specific to that category. Again, it is a way to help us document, organize our visits with our patients, and it can be a mixture of a bullet point and also written narrative, depending on your practice setting they will require it be in narrative form in sentences. Other places it can be just quick bullet points, so definitely when you moved here clinical practice ask about how they like you and expect clinicians to document. Again, it is slightly different from the medical SOAP note, and it is really that there is less of a focus on the medical testing and review of systems that you might be familiar with from your health assessment course taken prior to this course.

Slide 4

Exactly what does it look like? It depends on the organization you work for. Some places it is still on paper and you have to document it in paper form; others it is on the electronic health record so it might be on your computer or specific to the Internet at your setting. Really, the link varies on the case. Sometimes if it's a quick follow-up with the patient your psychiatric SOAP note will be really short. Other times you might have a more intensive case that requires a lot more and there's a lot more going on. You might have psychosis and substance use and social issues going on, and that is going to mean that you're going to have to evaluate more things and also make more of an effort on the treatment plan in terms of medications and involvement of family and friends. In the psychiatric nurse practitioner program here at Regis it is important that we understand what the psychiatric SOAP note looks like compared to the medical SOAP note. This is really just to help understand our patients and organize our information to facilitate patient treatment planning and diagnosis.

Slide 5

It is really a way for clinicians to communicate with each other, too. The four components are the Subjective, Objective, Assessment, and Plan. We will go into detail on each of those.

Slide 6

This is a slide that is taken right from the template that you can refer to it is also posted in Moodle. The S stands for Subjective, and it includes the chief complaint, any subjective information (so what the patient tells you), as well as some basic demographic information from the patient. You also want to include any relevant information to what is occurring at the moment, what the patient reports is happening, and some brief past medical history and psychiatric history as well as social history.

Slide 7

The components (this goes into more detail of the S, the Subjective section) and it helps break down exactly what should be included in this area of your psychiatric SOAP note. This is really to help paint a picture and capture what this patient - what is happening for this patient in the moment, as well as a little brief background about what happened prior to seeing this patient in clinic.

Slide 8

The O is the Objective, so this is really the facts of the case. You want to think of it as what you would be able to actually monitor and assess at that appointment. This could include vital signs. You might take vital signs in your clinic practice. It can also include lab results if they are in an ER setting and they obtain labs peer there's also mental status exam, which we do go into detail in another lesson plan, so definitely check that out to see specifically what needs to be included in that MSE. The MSE does need to be complete in a psychiatric up SOAP note so be sure that you are documenting everything within the MSE. You will also document the risk assessment. The risk assessment is assessing if the patient is feeling safe, if they have any suicidal ideation (thoughts or plans), homicidal ideation (thoughts/plans), or if there is any intent to go forth with those thoughts or plans, as well as any contributory factors that are causing these thoughts and feelings as well as what in the patient's life is helpful to prevent them from moving forward with their plans. Again, that is also another lesson so be sure to take a look at what the risk assessment specifically includes.

Also, the psychiatric screening measure results, so depending on what your patient presents with in your practice, you are going to complete a screening measurement. This could be the Hamilton Depression Screening Tool. This might be the AUDIT Tool, CAGE which is for substance use and depression, there's a whole host of them for ADHD and OCD, so depending on what you see with the patient you might choose to do one of the screenings. Screenings can be found on different organization websites. There are some really good ones on the American Psychological Association website and you might also consult with your mentor, your clinical preceptor, or faculty for additional tools. It is a good idea to start putting together a toolbox for when you are in practice, so start thinking about that now.

Slide 9

This just goes into more detail about the objective section. One thing I do want to really make clear in this section is the review of systems, so this is really what makes the psychiatric SOAP note very different from the medical SOAP note. The review of systems in the psychiatric SOAP note is very, very brief - very basic. You will be taking a quick review of the patient's systems (is there any problems with your cardiac system, is there any problem with breathing, shortness of breath? Are there any difficulties with their GI system?) You're going to go through the systems very briefly, and if there is nothing that is significant you are going to document that, it was noncontributory or nonsignificant. If there is a finding that is positive you will just document that finding is positive, so if the patient is coming in with hand tremors you would want to document that. ";The review of systems is noncontributory and negative except for hand tremors,"; so it is really very basic. Just include what is relevant and what is positive finding whereas with your medical notes you will likely go into much greater detail with the cardiac system. You would want to find out a lot more information, but this is just a real overview of any critical issues at this time.

Slide 10

The A is the Assessment. Again this is on your template. Here you are going to go through what you found (diagnosis, differentials) so you want to include what you think is the diagnosis that this person has. There might be one, there might be two, there might be a few that you would want to include here. It might be based on a diagnosis you make. It might be a diagnosis that a previous clinician made, but you want to document that here. The differentials are other diagnoses that you would want to consider, so things that you aren't certain about at this time but you want to continue to evaluate over time to see if the patient does, in fact, exhibit symptoms of that diagnosis. Somebody with symptoms of depression, you might - and they are going through a difficult time. There's situational issues in their life, you might not necessarily make the diagnosis of depression, but instead have a differential diagnosis to continue evaluating them. As you collect more information you can make that determination about whether you want to make it an actual diagnosis. You should look at the DSM V. That is where you will find the criteria for the diagnoses, so take a look at those.

There's also ICD 10 codes. These codes are for billing purposes. It is really important that you take a look to see what these ICD 10 codes are for each diagnosis. They are challenging to learn in the beginning, and with some time I'm sure you will end up memorizing them actually for some of the common ones. You can find the ICD 10 codes by googling them. There are some really good resources online for matching the DSM V diagnoses to ICD 10 codes. A lot of your practice areas will require that you include the ICD 10 codes, so it's a good idea to start practicing them now. You are also going to include any treatment options for the patient, any recommendations that you are making based on the patient's diagnosis and any obstacles you expect that the patient might have moving forward with plans that you are going to go through in the upcoming slides.

Slide 11

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Aspects of ";A";

Working primary diagnosis; current differential diagnoses; concurrent diagnoses including medical diagnoses; DSM V diagnoses, ICD 10 codes.

Slide 12

Your P, the PE is really about the plan, so what are you doing? What is the plan for the patient going forward from this appointment on? You want to include any medication changes you've made, any dosing changes, titration considerations, so if the patient is going to be seen in your office in a week you want to include that information as well, and then you want to include any holistic options - if you recommended acupuncture or exercise, if you have made any referrals to other psychiatric providers, therapists, medical providers you want to make sure to include that here as well.

Slide 13

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Aspects of ";P";

Diagnostic: collateral information, releases obtained, safety planning, testing plans.

Specific treatment: medications (dose, route, titration plan), psychotherapy plans, education, nonpharmacologic interventions (nutrition, exercise).

Disposition: Steps, follow-up plan, potential future treatment steps.