The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based
The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.
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Initial Psychiatric Interview
Student’s name
Institution affiliation
Course
Instructor’s name
Date
Initial Psychiatric Interview/SOAP Note Template
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Criteria |
Clinical Notes |
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Informed Consent |
Patient was alert, oriented x3 and provided verbal consent to participate in the assessment. |
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Subjective |
Verify Patient Name: DB DOB: 50-year-old African American female Minor: No Accompanied by: Patient was unaccompanied Demographic: N/A Gender Identifier Note: Female CC: “I have been feeling stable and I'm taking all my medications" HPI: DB is a 50-year-old African American female presenting for a mental health assessment. She reports taking all of her medications and states that her mood is stable. She reports sleeping and appetite are ok. She is currently attending a methadone program 3 days per week and reports taking 47 mg of methadone daily. DB was alert and oriented x3 during assessment, had proper eye contact, and denied any SI/HI or auditory hallucinations. Pertinent history in record and from patient: Patient has a past diagnosis of schizoaffective disorder, bipolar type. During assessment: The patient reports taking all of her medications, sleeping and appetite are okay, and attending a methadone program 3 days per week. Patient reports taking 47 mg of methadone daily, denies any SI/HI or auditory hallucinations, and states her mood is stable SI/ HI/ AV: Patient denies any suicidal or homicidal ideation, auditory or visual hallucinations. Allergies: No allergies reported Past Medical History: No medical history reported Medical history: Denies any past medical issues. Past Psychiatric History: Patient has been previously diagnosed with schizoaffective disorder bipolar type. She reports previous medication trials and has no history of violence to self or others. Previous psychiatric diagnoses: schizoaffective disorder, bipolar type. Patient describes stable mood. Previous medication trials: Patient reports taking 47 mg of methadone daily. Safety concerns History of Violence to self: none reported History of Violence to others: none reported Auditory Hallucinations: Patient denies any auditory hallucinations. Visual Hallucinations: Patient denies any visual hallucinations. Mental health treatment history History of outpatient treatment: Patient reports attending a methadone program 3 days per week and taking 47 mg of methadone daily. Previous psychiatric hospitalizations: No prior psychiatric hospitalizations reported. Prior substance abuse treatment: Patient is attending a methadone program 3 days per week. Trauma history: None reported Substance Use: Patient reports using methadone daily and denies any other substance use. Client report taking 47 mg of methadone daily. Current Medications: 47 MG of methadone Past Psych Med Trials: None reported Family Medical History: Not mentioned Family Psychiatric History: Substance use: No substance use reported Suicides-none Psychiatric diagnoses/hospitalization-none Developmental diagnoses-none Social History: Occupational History: None reported Military service History: Denies previous military history. Education history: No education history reported Developmental History: None reported Legal History: None reported Spiritual/Cultural Considerations: none reported. ROS: Constitutional: No report of fever or weight loss. Eyes: Eye contact was appropriate during assessment. ENT: No report of hearing loss, tinnitus, or vertigo. Cardiac: No report of chest pain or dyspnea. Respiratory: No report of cough or wheezing. GI: No report of nausea, vomiting, or abdominal pain. GU: No report of dysuria or hematuria. Musculoskeletal: No report of joint pain or stiffness. Skin: No report of rash or lesions. Neurologic: No report of weakness, numbness, or dizziness. Hematologic: No report of bleeding or easy bruising. Allergy: No report of allergies. Reproductive: No report of menstrual irregularities. |
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Objective |
Temp: 98.6 BP: 120/80 HR: 80 R: 16 O2: 98% Pain: 0/10 Height: 5’9” Weight: 160 lbs. BMI: 25.7 BMI Range: Normal LABS: Lab findings WNL Tox screen: Negative Alcohol: Negative HCG: Negative Physical Exam: MSE: Patient was alert, oriented x3, and had no physical distress noted. Presents with appropriate eye contact. TC: Patient was cooperative and had proper eye contact throughout the assessment. |
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Assessment |
DSM5 Diagnosis: with ICD-10 codes Dx: Schizoaffective disorder bipolar type Dx: Substance Use Disorder, Moderate The patient meets criteria for schizoaffective disorder bipolar type as per the DSM-5. This disorder is characterized by a period of a major mood episode, either manic or depressive, that occurs with psychotic symptoms. The patient reported having a stable mood, taking all of her medications, and attending a program 3 days per week and methadone clinic. This is indicative of a stable mood disorder. According to the DSM-5, schizoaffective disorder bipolar type is diagnosed when the patient has a period of illness that consists of a major mood episode (either manic or depressive) concurrent with the active-phase symptoms of a schizophrenia spectrum disorder (Noel & Jackson, 2020). |
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Plan (Note some items may only be applicable in the inpatient environment) |
Inpatient Psychiatric: bipolar as per DSM-5 criteria Estimated stay: 4 days Safety Risk/Plan: Patient is found to be at low risk for violence to self or others and denied any SI/HI or auditory hallucinations. Pharmacologic interventions: The patient should continue her current dosage of 47 MG of methadone daily and should be evaluated for additional medications to help manage her schizoaffective disorder bipolar type. Possible medication interventions include mood stabilizers, antipsychotics, and antidepressants. Mood stabilizers such as lithium, valproic acid, and carbamazepine can help to stabilize mood and reduce manic and depressive episodes. Antipsychotics such as risperidone and olanzapine can be used to reduce psychotic symptoms (Martinotti et al., 2022). Antidepressants such as fluoxetine and sertraline can be used to help manage depressive symptoms. In the case of the patient, she should be evaluated for the need for additional medications to help manage her schizoaffective disorder bipolar type. Referrals: Patient should be referred to a psychiatrist for further management and monitoring of her schizoaffective disorder bipolar type. Follow-up: Patient should follow up with the psychiatrist in 1-2 weeks. Time spent in psychotherapy: Patient should attend weekly psychotherapy sessions Visit lasted: The visit lasted 45 minutes |
References
Martinotti, G., Chiappini, S., Mosca, A., Miuli, A., Santovito, M. C., Pettorruso, M., … & Giannantonio, M. D. (2022). Atypical antipsychotic drugs in dual disorders: current evidence for clinical practice. Current Pharmaceutical Design, 28(27), 2241-2259. https://www.ingentaconnect.com/content/ben/cpd/2022/00000028/00000027/art00004
Noel, J. M., & Jackson, C. W. (2020). ASHP therapeutic position statement on the use of antipsychotic medications in the treatment of adults with schizophrenia and schizoaffective disorder. American Journal of Health-System Pharmacy, 77(24), 2114-2132. https://academic.oup.com/ajhp/article-abstract/77/24/2114/5900255
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