SOAP Notes
Each student will complete three (3) SOAP notes. SOAP Notes are to be posted to the DB in a copy
& paste fashion for ease of reading and reference. Please do not attach a link to the document These
Soap Notes will stimulate discussion, questions, and critique by peers and instructors. Soap Notes are
to be posted in weeks 1, 5, and 9 by Sunday at 11:59. Discussion including at least one meaningful
response to at least one of your peers’ Soap Notes should occur by Wednesday at 11:59pm EST in
weeks 2, 6, and 10. A meaningful response is one that demonstrates critical thought. Refer to the
Carlat, Robinson and Sadock, Sadock & Ruiz texts for assistance. Posts that are perfunctory or only
minimally meeting all grading criteria do not necessarily qualify as “excellent” which would yield full
points (100). This is true for both the initial post and the response post. One response post is
considered to minimally meet criteria. Refer to the SOAP Note Grading Rubric.
Discussion responses and responses to other required student posts should be a minimum of 150
words, scholarly written, APA formatted, and referenced. A minimum of 2 references are required
(other than the course textbook). Refer to the Grading Rubric for Online Discussions for grading
criteria.
Purpose: To record information from the patient, family members, friends, other data bases,
other professionals (nurses, physicians, labs, X-ray, Etc.), in order to accurately ascertain the
information which you need to know about the patient and their disease process(es), so that you
can make an accurate diagnosis and provide advice on the most appropriate treatment. The
written record also provides a means of communication between you and your professional
colleagues. It should be written in a manner which allows the reader to “see” what you
observed, performed, discussed and plan to do for and with the patient. SOAP notes are
generally done as a follow up after an initial H & P (Psychiatric evaluation) has been done.
Criteria
A.
S Subjective data appropriately documented. Chief complaint, interval history and review of
symptoms.
B.
O Objective data appropriately documented. Vitals, review of testing and lab work, MSE.
C.
A Assessment appropriately documented. Review diagnoses and current treatment plan for
accuracy and relevance.
D.
P Plan to include cost-effective and evidence-based treatment. Include labs to order, meds
and dosage, counseling and referrals, teaching plan, follow up (add to what was done if you
would do something other than your preceptor- in italics).
E.
Include neurobiology of disorder(s). (Include genetics, neurotransmitters, neuroanatomical
changes, current theories of causation, cultural factors).
F.
Rationale for each part of management plan (labs; meds: why this med, what is neurochemistry
action of med, side effects to monitor, expected benefits, contraindications; counseling-goals,
rationale for this type of therapy, expected benefits, teaching, referrals, follow-up). Include
references from at least 3 sources including one article from refereed journal.
Syllabus NSG 536: 2021- 2022
SOAP NOTE FORMAT/EXAMPLE: (Note: This example is not exhaustive and yours must include
additional data such as elaboration of rationale, neurobiology, or other information important for an
academic exercise but not necessarily appropriate for a clinical document in practice)
PSYCHIATRIC PROGRESS NOTE (SOAP)
NAME: Doe, John
DATE: 05/1/2021
Subjective: CC: “I was in the hospital”. John is seen today as a status post hospitalization visit. He
was hospitalized at from 04/26/21 to 04/30/21. He was apparently admitted for increased agitation and
aggression, making threats toward his mother and his niece, with whom he had been living. John states
that he does not believe he had been taking his medications correctly, but he also acknowledges that
there was increased stressors at the time of hospitalization with his mother and his niece. It is not clear
how long John had been living with his mother and niece. The last time he was seen at this clinic was
in March of 2010 and he was a resident of Bellvue Personal Care Home. He now resides back at
Bellvue Personal Care Home after discharge. John was stabilized and then discharged on his previous
medication regimen. He was given a diagnosis of Chronic Paranoid Schizophrenia. However, John
appears to have a significant mood component and has been diagnosed with Schizoaffective Disorder,
which will continue to be his working diagnosis. John also states that he has quit smoking. He has not
smoked in six days and plans to continue abstinence. His sleep, appetite, and weight remain stable.
Objective MSE: The patient is casually dressed and groomed. He looks very good today. He has good
skin color. He is alert. He appears to be in good spirits. He makes good eye contact. He is calm and
cooperative. Speech is regular in rate and tone, relevant, with some latency of response. Thoughts
appear to be goal directed. He relates his mood as “good”. Affect is restricted. He denies any mood
lability or instability, nor is there any noted. There is no evidence of any delusional thinking. There is
no evidence of any perceptual disturbances. There is no evidence any suicidal or homicidal ideation
and he denies same. He is alert and oriented X three.
Assessment:
Schizoaffective Disorder, Nicotine Use Disorder, Panic Disorder with Agoraphobia, Mild
Intellectual Disability, Peptic Ulcer Disease; Gastritis; Hyperlipidemia; Obesity; Type II
Diabetes; Early Diabetic Retinopathy; Disc Disease; Abnormal Tongue Movements; History of
Thyroid Disease; Recent hospitalization and Housing issues
Current Medications:
a. Geodon 80 mg, po bid
b. Clonazepam 1 mg po qid
c. Fluoxetine 40 mg one po q day
d. Lithium Carbonate 300 mg, three tablets po q h.s.
Plan:
Continue with John’s current medication regimen. He has been doing well since discharge. He relates
that he has been getting along with everyone at Bellevue. He has not had any further problems with
anger, aggression, or agitation. During his previous residence at Bellevue, he was somewhat
disgruntled and was seeking different housing; however, it appears that once than happened and he
moved in with his mother his stressors increased and he destabilized. He is working with his
Syllabus NSG 536: 2021- 2022
caseworker to find alternative housing that would be appropriate. He will also continue in outpatient
therapy with. John verbalizes understanding of, and agrees with, this treatment plan. He is encouraged
to contact this office with further questions or concerns. He will be return to the office in four weeks for
reevaluation, or sooner, as needed.
*Include neurobiology of disorder(s). (Include genetics, neurotransmitters, neuroanatomical
changes, current theories of causation, cultural factors).
*Rationale for each part of management plan (labs; meds: why this med, what is neurochemistry action
of med, side effects to monitor, expected benefits, contraindications; counseling-goals, rationale for this
type of therapy, expected benefits, teaching, referrals, follow-up). Include references from at least 3
sources including one article from refereed journal.
Signature/credentials
Syllabus NSG 536: 2021- 2022
Syllabus NSG 536: 2021- 2022
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