Infant or Toddler (Under Age 6). Step 2: Each student will create a focused SOAP note or PowerPoint presentation. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive psychiatric SOAP note or PowerPoint is to be written using the attached template below. Do not provide a voiceover or video for the PowerPoint. Only the information asked in the video will be used for grading.
S =
Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS). Click hereLinks to an external site. for more details
O =
Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; and Mental Status Exam
A =
Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes
P =
Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up. Psychiatric SOAP Note Template
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
SI/HI: _______________________________________________________________________________
Sleep: _________________________________________ Appetite: ________________________
Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________
Current perception of Health: Excellent Good Fair Poor
Psychiatric History:
Inpatient hospitalizations:
Date Hospital Diagnoses Length of Stay
Outpatient psychiatric treatment:
Date Hospital Diagnoses Length of Stay
Detox/Inpatient substance treatment:
Date Hospital Diagnoses Length of Stay
History of suicide attempts and/or self injurious behaviors: ____________________________________
Past Medical History
• Major/Chronic Illnesses____________________________________________________
• Trauma/Injury ___________________________________________________________
• Hospitalizations __________________________________________________________
Past Surgical History___________________________________________________________
Current psychotropic medications:
_________________________________________ ________________________________
_________________________________________ ________________________________
_________________________________________ ________________________________
Current prescription medications:
_________________________________________ ________________________________
_________________________________________ ________________________________
_________________________________________ ________________________________
OTC/Nutritionals/Herbal/Complementary therapy:
_________________________________________ ________________________________
_________________________________________ ________________________________
Substance use: (alcohol, marijuana, cocaine, caffeine, cigarettes)
Substance Amount Frequency Length of Use
Family Psychiatric History: _____________________________________________________
Social History
Lives: Single family House/Condo/ with stairs: ___________ Marital Status:________
Education:____________________________
Employment Status: ______ Current/Previous occupation type: _________________
Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________
Sexual Orientation: _______ Sexual Activity: ____ Contraception Use: ____________
Family Composition: Family/Mother/Father/Alone: _____________________________
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________
________________________________________________________________________
Health Maintenance
Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____
Exposures:
Immunization HX:
Review of Systems:
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
Physical Exam
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (percentile) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
Mental Status Exam
Appearance:
Behavior:
Speech:
Mood:
Affect:
Thought Content:
Thought Process:
Cognition/Intelligence:
Clinical Insight:
Clinical Judgment:
Plan:
Differential Diagnoses
1.
2.
Principal Diagnoses
1.
2.
Plan
Diagnosis #1
Diagnostic Testing/Screening:
Pharmacological Treatment:
Non-Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Diagnosis #2
Diagnostic Testingg/Screenin:
Pharmacological Treatment:
Non-Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Signature (with appropriate credentials): __________________________________________
Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________
DEA#: 101010101 STU Clinic LIC# 10000000
Tel: (000) 555-1234 FAX: (000) 555-12222
Patient Name: (Initials)______________________________ Age ___________
Date: _______________
RX ______________________________________
SIG:
Subjective:
Chief Complaint: The parents of a 2-year-old male child are seeking an Assessment for concerns about delayed speech and language development.
History of Present Illness: According to the parents, the child says fewer than 10 words and does not combine words. He primarily uses gestures to communicate wants and needs. No other developmental concerns were reported.
Objective:
Medications: None
Allergies: No known drug allergies
Past Medical History: Unremarkable, full-term vaginal delivery
Family History: Father had delayed speech as a child but caught up by age 4. No other pertinent family history.
Social History: Lives with parents and 4-year-old sister. Attends daycare part-time. Meets milestones in other areas of development.
Review of Systems: Otherwise unremarkable.
Mental Status Exam: Alert, attentive, makes good eye contact. Able to follow simple 1-step commands. Points to body parts and pictures when named. No concerning behaviors observed.
Standardized Testing: Peabody Picture Vocabulary Test showed receptive language skills at the 12-month level.
Assessment:
Primary Diagnosis: Expressive and receptive language disorder (ICD-10: F80.1; DSM-5: 315.31)
Differential Diagnoses:
Social communication disorder (ICD-10: F80.8; DSM-5: 315.39)
Childhood-onset fluency disorder (ICD-10: F80.0; DSM-5: 315.35)
Plan:
Referral to early intervention speech therapy 2x/week (1, 2)
Monitor development and reassess in 6 months (3, 4)
Provide parents with communication strategies to use at home (5)
References:
American Speech-Language-Hearing Association. (n.d.). Speech sound disorders: Treatment. https://www.asha.org/public/speech/disorders/Speech-Sound-Disorders/
Paul, R., & Roth, F. P. (2011). Characterizing and predicting outcomes of communication delays and disorders in early childhood: Implications for health care policy and delivery. Journal of developmental and behavioral pediatrics: JDBP, 32(6), 496–503. https://doi.org/10.1097/DBP.0b013e318222be30
Zimmerman, I. L., Steiner, V. G., & Pond, R. E. (2011). Preschool Language Scale. Pearson.
Centers for Disease Control and Prevention. (2020, October 13). Learn the Signs. Act Early. https://www.cdc.gov/ncbddd/actearly/pdf/parents_pdfs/actearly_brochure_eng.pdf
Kaiser, A. P., & Roberts, M. Y. (2013). Parent-implemented enhanced milieu teaching with preschool children who have intellectual disabilities. Journal of speech, language, and hearing research : JSLHR, 56(1), 295–309. https://doi.org/10.1044/1092-4388(2012/11-0231)
