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: Outpatient psychiatric treatment: Detox/Inpatient substance treatment:
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) 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: