SOAP note Sample for PMHNPs – Clinical SOAP Note Example

Here’s a SOAP Note sample OR Clinical SOAP Note Example for PMHNPs that scored 20/20 as the Unit 14 Assignment – Clinical SOAP Note. Use it as a guide when writing your SOAP note, or let our nursing writers do your SOAP note for you.

SOAP NOTE OUTLINE

Clinical SOAP Note Sample

Client ID:  Initials: BR, AGE: 67, Demographic: Caucasian, Gender: F

Clinical SOAP Note Sample Subjective

Chief complaint: BR complains of “forgetfulness and sluggishness.”

Source of reliability: The reliability of information is good. The caregiver is an adult in the right state of mind.

Present illness: BR complains of persistent forgetfulness and sluggishness. She notes that she had an accident 30 years ago that claimed his spouse’s life. She had brain surgery following the trauma. Although she experienced memory lapses, she fully recovered. The caregiver reports that BR cannot remember common words and communicate appropriately. Sometimes, she forgets where she kept her mobile phone, my name, and the days of the week. She admits to being a chronic alcohol addict but has since stope due to her memory issues. She becomes irritated and aggressive whenever she cannot remember “stuff.”

SOAP Note sample OR Clinical SOAP Note Example for PMHNPs

What to learn more about soap notes? You might find these interesting

• What is a SOAP Note? [Subjective, Objective, Assessment, and Plan Examples]
• SOAP NOTE SUBJECTIVE Examples [UPDATED]
• SOAP Notes Assessment Examples | Guide & Outline
• Clinical SOAP Note Depression (SOAP notes for mental health examples)

Current psych meds:  None reported.

Past Psychiatric Hx: No psychiatric diagnosis or hospitalization.

Past Medical Hx: No reported respiratory, CV, GI, CNS, GU, or MSK issues.

Surgical history: Brain surgery following an accident.

Allergies: NKFDA

Substance use/abuse: Chronic alcohol and tobacco abuse.

Past family, social history:

Family psych hx: Widowed for the past 30 years. Has three male children, alive and well.

Social Hx: Normal upbringing. Liked partying and drank heavily. Never driven while drunk. Education/Employment/Disability: High school diploma. Worked as a bartender and bar manager. No disability.

Primary support system: Children.

Hobbies: Gardening.

Review of systems (ROS):

Constitutional: No fever or chills

Eyes: Vision intact.

ENT: Hearing and sense of smell intact. No difficulty swallowing.  

Skin: No itchiness or rash.

Cardiovascular: No chest pain/discomfort.

Respiratory: Normal heart rate. No dyspnea.

GI: Reports loss of appetite. Denies n/v/. No abdominal pain.

GU:  No burning urination. No Pregnancy. Last menstrual period, 09/02/2021.

MSK: On and off joint pain. No swelling.

Neurologic: No seizures or numbness. Knee weakness when intoxicated.

Endocrine: No polyuria.

Clinical SOAP Note Sample Objective.

Vital Signs: Stable

Temp: 98.9 F, BP: 118/75, HR: 71, R: 17, O2: 92, Ht: 5’5’’, Wt: 120lbs, BMI: 20 kg/m²

Appearance: Well dressed. Fair eye contact.

Attitude/interaction: Calm and withdrawn.

Activity level/behavior: In acute psychological distress. Present: psychomotor retardation or agitation.

Orientation: Appears disoriented.

Speech: Repetitive and slow.

Thought content/process/perception: Thoughtform and content is scattered. Has poor perception.

Mood/affect: Mood stated as depressed. Appears blunted and restricted.

Judgment/insight/cognitive/memory: Poor judgment and insight. Memory is below average.  Experience difficulty with abstract thought.

Attention: Limited attention and concentration (SOAP note plan example)

Physical Exam:

Abdomen: Normal abdominal symmetry. Tenderness on the lower right abdomen.

Musculoskeletal: Full ROM in all extremities. No edema, clubbing, or effusion. (Unit 14 Assignment – Clinical: SOAP Note (SOAP note plan example)

Testing:

UDS: Negative.

Tox screen: Positive

Here are SOAP Notes For Mental Health Examples

Clinical SOAP Note Sample Assessment.

1. Mild neurocognitive disorder (NCD) due to Alzheimer’s disease with behavioral disturbance. ICD-10 code is F02.81.  BR presents symptoms synonymous with individuals diagnosed with NCDs due to Alzheimer’s disease. These symptoms include a gradual progression of cognition, learning, and memory impairment (American Psychiatric Association, 2013). Moreover, BR does not prevent any other neurodegenerative or cerebral illness likely to contribute to cognitive decline. This is the primary diagnosis.
2. Alcohol-induced mild neurocognitive disorder with behavioral disturbances. ICD-10 code is FI 0.988. BR neurocognitive impairment symptoms persist beyond the period of intoxication and withdrawal, indicating a possible substance-induced neurocognitive impairment (American Psychiatric Association, 2013). This diagnosis is refuted.
3. Mild neurocognitive disorder due to Parkinson’s disease with behavioral disturbances. ICD-10 code is (F02.81. BR presents symptoms of NCD not attributed to other medical conditions and shows signs of gradual progression of impairment crucial for NCD diagnosis (American Psychiatric Association, 2013). However, PD symptoms do not precede NCD. This diagnosis is refuted.
4. Mild neurocognitive disorder due to traumatic brain injury. ICD-10 code is F02.81. BR meets the criteria for NCD and presents amnesia, disorientation, and confusion crucial for diagnosis of NCD with traumatic brain injury (American Psychiatric Association, 2013). However, BR does not have a history of loss of consciousness, and the symptoms do not present following a traumatic brain injury or recovery. This diagnosis is refuted.
5. Mild Vascular Neurocognitive Disorder with behavioral disturbance. ICD-10 code is F01.51. BR symptoms meet the diagnostic criteria for NCD and present symptoms such as cognitive deficits and slow speech (American Psychiatric Association, 2013). However, BR does not have a history of cerebrovascular disease, and the symptoms are not consistent with vascular etiology crucial for vascular NCD diagnosis. This diagnosis is refuted.

Clinical SOAP Note Sample Plan.

Treatment Goals:

• Enhance memory and cognition
• Minimize wandering behavior
• Establish a safe living environment
• Enhance patient’s speech and understanding

Here’s a ADHD SOAP Note Example

Treatment Plan:

Start donepezil 10 mg PO QD and memantine 5 mg PO BDS to improve cognition. Donepezil effectively enhances patients’ social and cognitive function in patients with mild-moderate Alzheimer’s dementia (Birks & Harvey, 2018). A combination of donepezil and memantine provides more significant cognitive, behavioral, and psychological symptoms in dementia patients with moderate-severe Alzheimer’s Disease (Chen et al., 2017). Maintain a safe environment and routine activities for BR and utilize pen and paper to communicate. Involving the patient and family members or the primary caregiver is crucial in making medical decisions, appropriate care, and maintaining autonomy (Whitlatch & Orsulic-Jeras, 2018). Visit GT, a psychotherapist for memory training, physical exercise programs, and psychological and social stimulation to enhance memory and cognition (Carrion et al., 2018).

Here’s a SOAP Note sample for PMHNPs that scored 20/20 as the Unit 14 Assignment – Clinical: SOAP Note. Use it as a guide when writing your SOAP note, or let our nursing writers do your SOAP note for you.

Next Visit: One week. For further assessment and recommendation.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing, Inc.   

Birks, J. S., & Harvey, R. J. (2018). Donepezil for dementia due to Alzheimer’s disease. Cochrane Database of Systematic Reviews, (6). https://dx.doi.org/10.1002%2F14651858.CD001190.pub3

Carrion, C., Folkvord, F., Anastasiadou, D., & Aymerich, M. (2018). Cognitive therapy for dementia patients: a systematic review. Dementia and Geriatric Cognitive Disorders, 46(1-2), 1-26. https://doi.org/10.1159/000490851

Chen, R., Chan, P. T., Chu, H., Lin, Y. C., Chang, P. C., Chen, C. Y., & Chou, K. R. (2017). Treatment effects between monotherapy of donepezil versus combination with memantine for Alzheimer disease: a meta-analysis. PLoS One, 12(8), e0183586. https://doi.org/10.1371/journal.pone.0183586

Whitlatch, C. J., & Orsulic-Jeras, S. (2018). Meeting the informational, educational, and psychosocial support needs of persons living with dementia and their family caregivers. The Gerontologist, 58(suppl_1), S58-S73. https://doi.org/10.1093/geront/gnx162

Here’s a SOAP Note sample for PMHNPs that scored 20/20 as the Unit 14 Assignment – Clinical: SOAP Note. Use it as a guide when writing your SOAP note, or let our nursing writers do your SOAP note for you.