I need 15 Psyciatric SOAP notes with fictitious patients with varying ages and varying DSM 5 diagnosis and appropriate medications. ( outpatient setting)
SOAP should have the following:
Chief Complaint:
HISTORY OF PRESENT ILLNESS:
Why did they seek treatment NOW?
What are the most problematic symptoms?
Precipitating factors/stressors
Severity and duration of current symptoms
What makes the symptoms worse? What helps?
Pertinent negatives
PHYSICAL REVIEW OF SYSTEMS:
Constitutional (recent fevers, chills, night sweats, weight loss/gain)
Cardiac (irregular heartbeat, fainting spells, dizziness, blackouts history of sudden death in the
family)
Endocrine (heat or cold intolerance, chills, fatigue, excessive thirst, excessive urination)
Gastrointestinal (distention, diarrhea, nausea, vomiting, constipation, abdominal pain)
Neurological (seizures, migraines, numbness/tingling, difference in sensory perception, vertigo,
vision changes, tremor, abnormal movements)
PAST PSYCHIATRIC HISTORY: Hospitalizations, psychotherapy, suicide attempts and
seriousness of suicide attempts. What was their experience with previous care? What treatments were helpful?
Psychotherapy
Hospitalizations
Suicide attempts
PREVIOUS PSYCHIATRIC MEDICATIONS: dates, brand and generic name of medication,
dose, how long medication was taken, side effects, indication and benefits and why it was
discontinued
CURRENT MEDICATIONS: name all current medications with generic name, dose, frequency
(include OTCs) and date of initiation
SUBSTANCE USE: First use and circumstances surrounding use, consequences of use (social,
legal, economic, relational, health), last use, pattern of use. Detox/Rehab? Any withdrawal signs
and symptoms? Ask specifically about quantities and classes of drugs, illicit and/or prescribed
FAMILY PSYCHIATRIC HISTORY (Grandparents, parents, siblings, children):
Completed suicides
Response to medication?
Previous diagnoses or self-diagnosed?
MEDICAL HISTORY:
Medical Illnesses (current and past history)
Surgical history
Allergies
PSYCHIATRIC ROS:
PHYSICAL EXAM: (Vital Signs, Weight, Height, Labs and any other diagnostic results or
images)
PSYCHOSOCIAL:
Born and raised where/by whom/siblings/birth order
Development and milestones
Education/performance/accommodations
Employment/Occupational history
Living situation
Marriage/relationships
Children
Employment
Legal History
Trauma/Abuse
Religious/Spiritual Beliefs
MENTAL STATUS EXAM:
DIFFERENTIAL DIAGNOSTIC IMPRESSION WITH FORMULATION:
3
Differential Diagnosis
Diagnosis with DSM 5 code
RECOMMENDATIONS AND PLAN
Specific medication and dosage