13 Mar SOAP NOTE TEMPLATE
Subjective Data
CC: is clear, concise and verbatim from pt.
HPI: is thorough yet concise and provides a chronological account of symptoms and contextual factors that are sufficiently descriptive (oldcarts) to validate Dx per DSM-5 criteria. All pertinent negatives are included. A longitudinal course of illness is clear. Current psychiatric medications and responses are included.
Medical History:
Surgical History:
Social History:
Mental Health History
Objective Data
Ht /Wt
Vitals
Mental Status Exam contains required elements.
Is in narrative form and effectively and vividly describes the patient’s presentation.
Concrete examples of all assessment results are included i.e.. “able to correctly interpret 2/3 simple proverbs” to validate documentation of “abstract thought intact”.
Actual diagnosis and Differential diagnosis are pertinent to signs and symptoms, the formulation contains evidence of critical thought and subject knowledge, and reasonable diagnoses are made per DSM-5. Clearly met criteria for diagnoses tendered are explicit in the HPI description and substantiated with the MSE
Plan
The evidence-based treatment plan is presented with detailed rationales.
The level of detail reflects the ability to choose treatments based not only on FDA approval or current evidence but also on the nuances and unique characteristics of each.
The treatment plan is holistic and comprehensive.
There is strong evidence of the synthesis of information and critical thought.
Includes neurobiology information on the disorder
Strong, recent (5-7 years), scholarly, peer-reviewed support of topics. No grammar, spelling, and punctuation errors. Writing mechanics are consistent with formal scholarly work. No errors in APA style based upon the required APA manuals listed on the course syllabi.
