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Give a brief summary of your thoughts about a psychiatric mental health initial assessment. Why is this critical to the care of the mental health patient? What areas were you surprised to see on a psychiatric mental health initial assessment?
Initial Psychiatric SOAP Note Template
There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to develop your style of SOAP in the psychiatric practice setting.
Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion)
Gender Identifier Note:
Pertinent history in record and from patient: X
During assessment: Patient describes their mood as X and indicated it has gotten worse in TIME.
Patient self-esteem appears fair, no reported feelings of excessive guilt,
no reported anhedonia, does not report sleep disturbance, does not report change in appetite, does not report libido disturbances, does not report change in energy,
no reported changes in concentration or memory.
Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. Patient does not report excessive fears, worries or panic attacks.
Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a characterological nature.
SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors.
(medication & food)
Past Medical Hx:
Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury.
Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C.
Surgical history no surgical history reported
Past Psychiatric Hx:
Previous psychiatric diagnoses: none reported.
Describes stable course of illness.
Previous medication trials: none reported.
History of Violence to Self: none reported
History of Violence to Others: none reported
Mental health treatment history discussed:
History of outpatient treatment: not reported
Previous psychiatric hospitalizations: not reported
Prior substance abuse treatment: not reported
Trauma history: Client does not report history of trauma including abuse, domestic violence, witnessing disturbing events.
Substance Use: Client denies use or dependence on nicotine/tobacco products.
Client does not report abuse of or dependence on ETOH, and other illi
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