Psychiatric SOAP Note Template

Encounter date: 09/03/23

Patient Initials: P.R.C Gender: M/F/Transgender _M_ Age: _25_ Race: _White_ Ethnicity: _Hispanic_

Reason for Seeking Health Care: The patient's mother provides a report of the patient exhibiting unusual

conduct, engaging in aimless wandering, and experiencing auditory hallucinations instructing him to

defend his nation against acts of terrorism. The individual states that “ I have a scheduled appointment with

a divine entity within the next several hours to discuss topics pertaining to personal safety, prior to my

enemies can kill me."

H.P.I.: The patient arrived at the Behavioral health clinic in the company of his mother. According to the

mother's account, the onset of symptoms occurred around one week before and has shown a progressive

deterioration over time. The symptoms manifested during the patient's attendance in a college program,

prompting the school administration to notify the parent and request psychiatric intervention due to the

patient's condition. The symptoms have persisted for about one week, without any documented complaints

of exacerbating or alleviating variables. The individual under consideration is a recognized mental patient

who has been undergoing treatment for Bipolar I illness for about one year. He has been prescribed a daily

dose of Olanzapine 10 mg by oral daily for the Bipolar I illness management. His mother figure rejects

any previous occurrence of such symptoms.

SI/HI: The patient rejects any presence of suicidal or homicidal ideas.

Sleep: the patient has a disturbed sleeping pattern but has no fatigue. He loiters during the day and night.
The individual engages in loitering both throughout daytime and nighttime hours.

Appetite: The patient exhibits a typical level of hunger but has difficulty in maintaining sustained

attention to complete their meals in a single sitting. The individual needs diligent monitoring and

encouragement in order to consume his meals in their entirety.

Allergies (Drug/Food/Latex/Environmental/Herbal): Both the mother and patient have provided

negative responses about any known allergies to medicine, latex, food, herbal substances, or

environmental factors.

Current perception of Health: Excellent Good Fair (as per the patient’s mother)

Poor

Psychiatric History:

Inpatient hospitalizations:

Dat Hospital Diagnose Length of

e s Stay

Both the patient and the mother have stated that there is no record of

the patient being admitted to a hospital for treatment in the past

Outpatient psychiatric Treatment:

Date Hospital Diagnoses Length of Stay

12/19/2022 Larkin Community Hospital to the Partial Bipolar I  (Monthly

Hospitalization Program (PHP) Disorder follow-up)

 Detox/Inpatient substance treatment:

Dat Hospital Diagnose Length of Stay

e s

The patient rejects a history of

detox/inpatient treatment.

History of suicide attempts and/or self-injurious behaviors: The patient's mother reports It was an

incident of a suicide attempt six months ago involving the ingestion of a sedative medication overdose.

Past Medical History

 Major/Chronic Illnesses: The individual is a diagnosed patient with bipolar I illness who

is currently receiving psychiatric care. The mother figure refutes any previous

occurrences of asthma, TB, diabetes, hypertension, and epilepsy.

 Trauma/Injury: The mother provides an account of a fracture occurring one month

subsequent to the diagnosis of bipolar I illness in the patient. This incident transpired

when the patient engaged in the act of leaping over a six-meter fence in order to get

access to a lawn tennis court situated within the vicinity.

  Hospitalizations: The individual was admitted to the hospital subsequent to the

occurrence of a fracture and subsequently had a surgical procedure known as open

reduction external fixation (OREF) in order to rectify the fracture.

 Past Surgical History: The present discourse pertains to the historical account of a tibia-

fibula fracture repair procedure conducted in the month of January in the year 2022.

 Current psychotropic medications:

P.O Olanzapine 10 mg  for Bipolar I disorder management.

 Current prescription medications:

P.O Olanzapine 10 mg  for Bipolar I disorder management.

O.T.C./Nutritionals/Herbal/Complementary therapy:

None

Substance use: (alcohol, marijuana, cocaine, caffeine, cigarettes)

Substance Amount Frequency Length of Use

Marijuana Two like rolls cigar three times per day Three years

Alcohol Two-1000 ml bottles Sporadic Two years

Family Psychiatric History: the parent denies a history of psychiatric illnesses.

Social History

Lives: Single-family House/Condo/ with stairs: single-family house Marital Status:

single.

Education: The individual is actively engaged in the pursuit of a Bachelor's degree in the

field of computer science.

Employment Status: student Current/Previous occupation type: the patient is

employed as a part-time worker in the field of internet sales and marketing for several

businesses.

Exposure to: Smoke: none ETOH: Periodic leisurely pursuits Drug Use: Marijuana

Sexual Orientation: Heterosexual. Sexual Activity: The patient is involved in a

romantic relationship with an individual attending college, nevertheless, the patient

asserts a lack of engagement in sexual activities or any corresponding desires during the

course of the previous six months.

Contraception Use: None.

Family Composition: Family/Mother/Father/Alone: According to the mother's account,

their family structure is characterized by a nuclear makeup. The individual under

consideration is the eldest offspring within a nuclear family consisting of two children.
 The younger sister is currently enrolled in a junior high school and is in good physical

condition.

Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx,

trauma, violence, social network, marital hx): the mother reports giving birth to her

son in the hospital, and no reports of complications during childbirth. She also denies

physical and mental health issues during the patient's childhood years. The patient's

hobby is watching movies and playing lawn tennis. He lives in the college hostels. The

mother reports concern over peer pressure at college that has exposed his son to drug

abuse (marijuana and alcohol). The mother and patient deny a history of violence or

arrest. The patient admits to having a girlfriend in college and several peer friends he

spends time with during his free time.

Health Maintenance

Screening Tests: Mammogram, P.S.A., Colonoscopy, Pap Smear, Etc : The patient

reports no previous record of undergoing screening for cancer.

Exposures: Inadequate nutritional choices. The mother figure reflects a significant

reliance on dietary items that are rich in sugar content and have undergone extensive

processing.

Immunization H.X.: The patient's immunization status is current, which includes the

administration of the COVID-19 vaccine.

 Review of Systems:

General: The patient presents episodes of heightened energy levels and a healthy appetite. The

patient reports the absence of cough or headache. Furthermore, the patient exhibits diminished

attentiveness throughout the interview

HEENT: The patient denies experiencing any headache or head trauma. The patient denies

experiencing any ocular discomfort, visual impairment, or pruritus in the eyes. The patient

further reports the absence of symptoms such as ear discomfort, ear fullness, abnormal ear

discharge, or tinnitus. The patient further reports the absence of symptoms such as nasal

congestion, rhinorrhea, sinusitis, and nasal dryness. The patient further refutes the presence of

tonsillitis

Neck: The patient has indicated the absence of any symptoms related to neck discomfort, edema,

or damage. The patient also reports experiencing limitations in neck flexibility

Lungs: The patient refutes experiencing any symptoms such as dyspnea, angina, respiratory

distress, or coughing. Additionally, he refutes any past medical records indicating a presence of

respiratory ailments

Cardiovascular: The patient exhibits no symptoms of angina, high blood pressure, severe

headache, hypotension, weariness, or blood clotting issues

Breast: The patient refutes the presence of significant breast alterations, such as gynecomastia,

palpable masses, enlargements, or abnormal muscle contractions

G.I.: The patient has indicated that their appetite is within the typical range. Nevertheless, the

mother notes her son's limited ability to concentrate while eating, necessitating continuous

prompting to ensure he finishes his meals. Mr. P.R.C does not report experiencing symptoms

such as nausea, vomiting, constipation, or diarrhea. The patient denies the presence of acid

reflux, stomach discomfort, bloating, abdominal pain, or soreness

Male/female genital: The patient denies the presence of aberrant penile discharge or alterations

in urine characteristics. The patient refutes engaging in sexual behavior in the recent past.

Additionally, he has diminished sexual drive

GU: The patient denies the presence of atypical penile discharge, such as hematuria or purulent

discharge. Additionally, the patient refutes experiencing dysuria, increased urination frequency,

urgency, reduced urine output, excessive urine production, or the presence of an unpleasant odor

Neuro: Mr. P.R.C exhibits symptoms of cognitive dissonance and aberrant conduct. The patient

denies experiencing symptoms such as dizziness, lack of feeling, numbness, or paresthesia

Musculoskeletal: The patient refutes experiencing symptoms of weariness, myalgia, or lethargy.

The individual reports experiencing a heightened sense of activity and energy. The patient denies

any musculoskeletal pathology

Activity & Exercise: The patient reports a lack of regular physical activity and exercise

Psychosocial: The patient asserts that the absence of marijuana results in heightened

productivity. Additionally, the individual asserts that alcohol has a calming effect on their

nervous system and cognitive faculties. The individual has a diminished affective state

characterized by a lack of emotional reactivity

Derm: The patient exhibits no evidence of cutaneous alterations, including irritation, dermatitis,

erythema, edema, contusions, or hypersensitivity responses

Nutrition: The patient indicates a typical level of hunger and desire to eat. Nevertheless, the

mother notes her son's limited ability to concentrate while eating, necessitating continual

encouragement to ensure he finishes his meals. The patient and his family heavily rely on easily

accessible sweet and processed food items

Sleep/Rest: The patient has a limited duration of sleep, averaging around two hours every night.

The individual remains idle in the absence of light,

L.M.P.: N/A

STI Hx: The patient denies any previous occurrence of sexually transmitted illnesses.

Additionally, the individual states that they engage in the practice of engaging in sexual activity

while using protective measures

Physical Exam

BP_120/89 mmHg__TPR_98.0 F_ HR: _90 b/m_ RR: _18 b/m_Ht. _185_ Wt. __90 kg__

BMI (percentile) _85-90

General: The individual in question has neglected personal cleanliness, resulting in an unpleasant

odor and disheveled hair. The individual exhibits signs of distress and irritability, however does

not display any aggressive behavior. The individual has a commendable posture and walk. The
individual exhibits a lack of temporal and situational awareness. His orientation is limited to

spatial and interpersonal aspects

HEENT: Head: The individual exhibits hair that is unbraided, displaying a consistent and evenly

distributed pattern. There are no palpable masses or regions of localized swelling, and no

evidence of surgical incisions or scars. The patient's ocular region exhibits signs of fatigue,

exhibiting a mild reddening and an atypical lack of moisture. The absence of jaundice,

conjunctival pallor, ness aberrant discharge is seen. The individual has optimal visual acuity.

There were no indications of abnormal discharge, pain in the ears, deformity, or perforation of

the eardrum. The patient exhibits no symptoms of epistaxis, rhinorrhea, nasal deformity, or

discomfort in the nasal region. The patient does not exhibit any signs of mouth breathing or nasal

flare-up

Neck: There is no discernible or tangible presence of bulk or swelling in Mr. P.R.C The

individual exhibits satisfactory flexibility, the absence of jugular distension, the absence of

lymphadenopathy, and the absence of an enlarged thyroid gland

Pulmonary: The patient exhibits regular respiratory patterns, without any signs of difficulty in

breathing, inward movement of the chest, or reliance on additional muscles for respiration. The

individual exhibits unremarkable breath sounds characterized by a hushed quality, without the

presence of any abnormal respiratory noises such as crackles, wheezes, or rhonchi. The absence

of crepitation or aberrant vibration is seen during the examination of bronchophony, egophony,

and tactile fremitus in the patient. Additionally, he has typical chest enlargement and chest

excursion
Cardiovascular: The patient exhibits blood pressure levels that are within the established range of

normalcy. The individual does not exhibit any symptoms of palpitations, venous distension,

varicose veins, or severe headache. The patient exhibits no tachycardia, bradycardia, nor

abdominal bruits. The individual exhibits no signs of palmar or conjunctival pallor. Both S1 and

S2 are audible, whereas there are no noises corresponding to S3 and S4. The individual exhibits

no signs of peripheral cyanosis, periorbital edema, or peripheral edema

Breast: Both mammary glands are present. There were no reported cases of dystonia or

gynecomastia. There is no presence of atypical discomfort or edema. The presence of flat nipples

is also seen

G.I.: The abdominal region has a boat-shaped appearance and lacks any visible indications of

surgical intervention. Bowel noises are audible in all four abdominal quadrants. There were no

abnormal sounds detected during auscultation. There is an absence of discomfort or sensitivity

upon palpation

Male/female genital: The patient has typical external genitalia with pubic hair that is of average

length and uniformly scattered. There is a noticeable odor present, perhaps resulting from

inadequate adherence to hygiene procedures. There is no evidence to suggest the need for further

evaluation

GU: The patient exhibits no anomalous discharge, such as pus or blood. There are no observable

physical manifestations of sexually transmitted infections (STIs), such as pruritus, ulceration, or

purulent discharge. There is no evidence to suggest the need for further evaluation.
Neuro: The patient has a favorable posture and walk. There are no indications of spinal injuries

or abnormalities present in his medical records. All of the cranial nerves are exhibiting normal

functionality, and the knee-jerk reflex elicits a positive response, graded as 2+. The individual

exhibits symptoms of confusion and cognitive impairment, as shown by observable changes in

their mental processes

Musculoskeletal: The patient has a satisfactory degree of joint mobility. There is an absence of

joint stiffness or irritation. The individual has satisfactory muscular strength, absence of any

musculoskeletal abnormalities, and an absence of fractures. The individual has a surgical scar

located on the lower extremity

Derm: The patient exhibits intact skin integrity, characterized by healthy and well hydrated skin,

without any signs of erythema, rashes, edema, or skin irritation

Psychosocial: The individual exhibits aberrant conduct and a diminished affect. The patient

refutes the presence of suicidal and homicidal ideas

Misc.

Mental Status Exam

Appearance: The patient has a little degree of excess body weight and has neglected personal

hygiene practices. The individual has disheveled hair. According to Amidfar et al. (2019), the

patient demonstrates orientation to both person and location. Nevertheless, it lacks a temporal

and event-based orientation. The patient exhibits a high level of irritability and restlessness.
Behavior: The individual exhibits unconventional conduct. The individual often engages in

aimless lingering and displays signs of irritability, however does not exhibit any tendencies

towards violence.

Speech: The individual exhibits articulate and intelligible verbal communication. He engages in

ongoing dialogue intermittently. The individual exhibits symptoms of forced speaking. In

addition, his oratory includes an average of one to two unfamiliar terms per every 20-30 minutes

of discourse. As an example, let us consider the term 'shukribarrshantan'

Mood: The patient has a flattened affect. The individual does not exhibit distinct symptoms of

despair, elation, or euthymic mood

Affect: The patient indicates a state of well-being, but expresses concern over the possibility of

attending a divine assembly in a timely manner and ensuring the safety of God's followers from

acts of terrorism. The individual's mood and emotion exhibit partial congruence

Thought Content: According to Amidfar et al. (2019), the individual exhibits symptoms of

grandiosity, as seen by their expressed intention to meet God. Additionally, they have auditory

hallucinations, characterized by hearing a voice that discusses the prevention of terrorist attacks.

The individual exhibits an absence of obsessions or compulsions. Furthermore, he does not own

any misconceptions

Thought Process: The individual exhibits symptoms of racing mind. The individual in question

exhibits a lack of tangentiality, circumferentiality, loose connection, and circumstantiality

Cognition/Intelligence: The individual exhibits impaired abstract thinking and judgment, as well

as diminished attention abilities. The individual exhibits an inability to solve the given proverb
(remaining silent), is unable to successfully do serial seven subtraction, and shows a significant

prioritization of saving a newborn above money in a burning residence (Amidfar et al., 2019)

Clinical Insight: The patient exhibits little clinical understanding of their situation

Clinical Judgment: Additionally, the patient has impaired decision-making abilities. The

individual affirms their well-being and expresses that they do not need mental healthcare

intervention
Significant Data/Contributing Dx/Labs/Misc.
The individual in question, Mr. P.R.C., is a 25-year-old male of White Hispanic ethnicity who
presents with manifestations indicative of a mental disorder. According to the mother's account,
the onset of symptoms occurred one week before and has shown a progressive deterioration. The
manifestation of symptoms occurred during the patient's academic session inside their college
program, prompting the school administration to initiate communication with the parent in order
to pursue psychiatric intervention. The symptoms have persisted for about one week, with no
documented complaints of exacerbating or alleviating causes. The individual in question is
recognized as a person with a mental health condition and has been undergoing treatment for
bipolar I illness for about one year. He has been prescribed a daily dose of 5 mg of Olanzapine for
post-operative care. The mother refutes any prior occurrence of such symptoms. The individual
exhibits an absence of thoughts or intentions related to self-harm or harm towards others.
Nevertheless, the individual has disclosed a pattern of regular marijuana use and sporadic
drinking of ethanol. He remains enrolled as a college student and lives in a single-family dwelling
with his parents. The individual exhibits symptoms of pressurized speech, auditory hallucinations,
impaired abstract thinking, and limited insight.

Plan:

Differential Diagnoses

1. Brief psychotic disorder (BPD) (F23; DSM-5 298.8). The disorder under consideration is

characterized by the abrupt emergence of psychotic symptoms, which last for a duration of

less than one month, afterwards leading to a full resolution of symptoms, but with the

potential for future recurrences. Schizophrenia is distinguished from schizophreniform

disease and schizophrenia by its distinct length of psychosis and other distinguishing traits

associated with schizophrenia. The individual exhibits atypical conduct, displaying signs of

cognitive impairment and a lack of orientation. Nevertheless, the individual exhibits

 symptoms such as hallucinations, grandiosity, and other distinctive characteristics often

associated with schizophrenia (Keepers et al., 2020).

2. Delirium (F 05; DSM-5 293). Delirium is characterized by a diminished perception of one's

environment, leading to impaired cognitive abilities, behavioral alterations, and emotional

fluctuations. The individual exhibits poor personal hygiene, cognitive impairment,

disorientation, irritability, and aimless wandering. Nevertheless, the individual exhibits

hallucinations, grandiosity, and other distinctive characteristics often associated with

schizophrenia (Keepers et al., 2020).

Principal Diagnoses

1. Schizophrenia, unspecified (F 20.9; DSM-5 295.90). Schizophrenia is a severe psychiatric

condition characterized by aberrant interpretations of reality. According to Ruderfer et al.

(2018), individuals diagnosed with schizophrenia may have hallucinations, delusions, and

severe cognitive and behavioral disturbances that significantly hinder their ability to carry

out everyday activities and may lead to disability. According to Keepers et al. (2020), the

individual exhibits symptoms of confusion, peculiar conduct, aimless wandering, cognitive

disorientation, and poor personal hygiene. Additionally, the individual exhibits symptoms

of auditory hallucinations, grandiosity, and a detachment from reality. Furthermore, his

cognitive abilities in abstract thinking, judgment, insight, and focus are notably deficient.

2. Bipolar I Disorder, unspecified (F 30.9; DSM-5 296.7). The individual in question has been

identified as a patient diagnosed with bipolar disorder type I for the duration of one year. He has

been attending regular monthly appointments at a mental center. The individual in question has
not had any hospitalization subsequent to their diagnosis. However, they do regularly visit the

Partial Hospitalization Program (PHP)iatric clinic located at Larkin Community Hospital. He has

been prescribed a daily dose of 10 mg of Olanzapine by mouth for Bipolar I

Disorder management .

Plan

Diagnosis #1 Schizophrenia, unspecified (F 20.9; DSM-5 295.90)

Diagnostic Testing/Screening: The assessment tools included in this study include the Mental

Status Examination, the Positive and Negative Syndrome Scale (PANSS), the Scale for the

Assessment of Negative Symptoms (SANS) and the Scale for the Assessment of Positive

Symptoms (SAPS), the Brief Psychiatric Rating Scale (BPRS), the Clinical Global

Impression-Schizophrenia (CGI-SCH), and the Calgary Depression Scale for

Schizophrenia (Keepers et al., 2020).

Pharmacological Treatment: P.O. Olanzapine 10 mg B.I.D x 1/12 (Keepers et al., 2020).

Non-Pharmacological Treatment: Psychosocial techniques include a range of therapeutic

interventions, such as psychoeducation, psychoanalysis, motivational interviewing, talk

therapy, family systems therapy, and cognitive-behavioural therapy. The aforementioned

techniques facilitate the maintenance of a stable mood by promoting a balance in dopamine

and serotonin levels.

Education: It is important for both the mother and the patient to possess knowledge about the

significance of medication adherence, the mechanism of action of the medicine, potential

side effects and adverse reactions, as well as any occurrences that need communication
 with the healthcare practitioner (Ruderfer et al., 2018). In order to enhance community

mental health and well-being, it is important for healthcare providers to provide

comprehensive education to families on available support services within the community.

This education should include psychosocial and family support options that may be used by

both the patient and their family (Keepers et al., 2020). The use of a patient-centered

approach and the incorporation of family-centeredness have shown to be efficacious in the

management of mental patients.

Referrals: none.

Follow-up: within 30 days

Anticipatory Guidance: Benefiting from psychosocial interventions and acquiring proficient

abilities in the use of psychosocial treatments to enhance mental well-being and mitigate

the risk of recurrence.

Diagnosis #2 Bipolar I Disorder, unspecified (F 30.9; DSM-5 296.7)

Diagnostic Testing/Screening: The assessment tools used in this study are the Mental Status

Examination, the Mood Disorder Questionnaire, and the Patient Health Questionnaire-9

(PHQ-9).

Pharmacological Treatment: P.O. Olanzapine 10 mg B.I.D 

Non-Pharmacological Treatment: psychosocial approaches include psychoeducation,

psychoanalysis, motivational talks, talk therapy, family interview, and cognitive-behavioral

 therapy. The approaches promote dopamine and serotonin balance, thus, facilitating a

stable mood.

Education: the mother and the patient need to be aware of the essence of medication adherence,

the mode of action of the drug, possible side and adverse effects, and events that warrant

reporting to the healthcare provider (López-Muñoz et al., 2018). The healthcare provider

should also educate the family on potential support resources in the community that the

patient and family can utilize for psychosocial and family support as part of promoting

community mental health and well-being. Patient-centered approach and family-

centeredness are effective in managing psychiatric patients.

Referrals: none.

Follow-up: 1 month

Anticipatory Guidance: The acquisition of benefits from psychosocial treatments and the

cultivation of proficient abilities in the use of psychosocial therapies to enhance mental

well-being and deter recurrence.

Signature (with appropriate credentials): A.A.C.R. R.N.B.S.N

Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________

 References

Amidfar, M., Woelfer, M., Reus, G. Z., Quevedo, J., Walter, M., & Kim, Y. K. (2019). The role

of NMDA receptor in neurobiology and Treatment of major depressive disorder:

evidence from translational research. Progress in Neuro-Psychopharmacology and

Biological Psychiatry, 94, 109668. https://doi.org/10.1016/j.pnpbp.2019.109668

Keepers, G. A., Fochtmann, L. J., Anzia, J. M., Benjamin, S., Lyness, J. M., Mojtabai, R., ... &

(Systematic Review). (2020). The American Psychiatric Association practice guideline for

the Treatment of patients with schizophrenia. American Journal of Psychiatry, 177(9), 868-

872. https://ajp.psychiatryonline.org/doi/abs/10.1176/appi.ajp.2020.177901

López-Muñoz, F., Shen, W. W., D’ocon, P., Romero, A., & Álamo, C. (2018). A history of the

pharmacological Treatment of bipolar disorder. International journal of molecular sciences,

19(7), 2143. https://www.mdpi.com/1422-0067/19/7/2143#

Ruderfer, D. M., Ripke, S., McQuillin, A., Boocock, J., Stahl, E. A., Pavlides, J. M. W., ... &

Freedman, R. (2018). Genomic dissection of bipolar disorder and schizophrenia, including

28 subphenotypes. Cell, 173(7), 1705-1715.

https://www.sciencedirect.com/science/article/pii/S0092867418306585
DEA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials) Mr. P.R.C Age 25 years

Date: 09/03/2023

RX

Olanzapine 10 mg tablet 

SIG: take 1 tablet of Olanzapine 10 mg twice at day.

Dispense: Olanzapine 60 tabs.

Refill: None.

Please follop up within a month with a psychiatrist.

 v No Substitution

Signature: A.A.C.R. R.N.B.S.N