Psychiatry
Share
Tweet
Cite
Click to rate this SOAPnote
[Total: 0 Average: 0]
approximately 21 views since raccoons became self aware.
PRESENTING CONCERNS

-- Emotional Distress --

[checkbox value="not reported|anxiety|depression|mood|suicide|performance anxiety|anger|fear|general distress|worrying|global distress|loneliness|guilt |shame|grief and loss"]

-- Self-Esteem/Concept --

[checkbox value="not reported|self-concept|self-esteem|identity|gender identity|self-efficacy|sexual orientation|adoption|feelings of abandonment|sense of belonging"]

-- Relationship Concerns --

[checkbox value="not reported|marital|friends|social group|interpersonal effectiveness|social support|family|interpersonal coping"].

-- Life Transitions --

[checkbox value="not reported|career|life decisions|academic|life tasks|life satisfaction"]

-- Physical Complaints --

[checkbox value="not reported|eating disorder|medical problem|injury|physical problems"]

-- Substance Abuse --

[checkbox value="not reported|alcohol|substance abuse|substance dependence"]

-- Self-Management --

[checkbox value="not reported|compulsive behavior|uncontrolled behaviour|phobias|obsessions|thought problems|sexual functioning|uncontrolled feelings|overt behaviour|social behavior|leisure time|leisure activities|procrastination|specific performance|coping skills|making friends|social anxiety|cognitive difficulties"]

-- Trauma --

[checkbox value="not reported|child abuse|recent trauma|ACE|war|victim of crime|injury|accident|unexpected death|unexpected loss"]

-- Psychosocial Stresses --

[checkbox value="not reported|poverty|homeless|oppression by others|cultural dislocation|arassmenth|unemployment|loss of peer group|divorce|separation|job stress|bullying"]

-- Achievement --

[checkbox value="not reported|career|life decisions|academic|life tasks|life satisfaction|specific performance"]

-- Physical Complaint--

[checkbox value= "not reported|eating disorders|physical problems|substance abuse|chemical abuse|fatigue"]

-- Indefinite --

[checkbox value="not reported|issues which need to be explored|my troubled past|a variety of concerns|all things are going wrong at this time|been avoiding problems for years|finding out what is bothering me|life stress|need to get back into a regular therapy arrangement|want to talk with someone on a regular basis|need someone to talk with about subjects on my mind|seeking support"]

-- Quality of Life --

[checkbox value="not reported|want to improve the quality of my life|wish to be happy|wanting to see life in new ways"]

PATIENT REPORT

[textarea cols=60 rows=20 default="Pt's story"]

NEUROVEG CONCERNS

[checkbox value="nil reported|sleep|energy levels|appetite|concentration"]

OBSERVATION

-- Appearance and Self-Care --

Stature: [select value="Average|Small|Tall"]
Weight: [select value="Average weight|Overweight|Obese|Underweight"] - Weight [text name="field_name" default="not assessed"]
Clothing: [select value="Neat/clean|Careless|Inappropriate|Meticulous|Disheveled Dirty|Bizarre"]
Grooming: [select value="Unremarkable|Meticulous|Neglected|Bizarre"]
Cosmetics: [select value="Unremarkable|Inappropriate for age|Excessive|None"]
Posture: [select value="Normal|Tense|Rigid|Stooped|Slumped|Bizarre"]
Motor activity: [select value="Unremarkable|Slowed|Repetitive|Restless|Agitated|Tremor"]
Other noticeable aspects: [textarea name="field_name" default="Nil"]

-- Sensorium --

Attention: [select value="Normal|Unaware|Inattentive|Distractible|Vigilant"]
Concentration: [select value="Normal|Scattered|Variable|Preoccupied|Confused|Anxiety interferes|Focuses on irrelevancies"]
Orientation Impairment: [checkbox name="Orientation" value="Nil|Time|Person|Place|Situation|Object"]
Memory Impairment: [checkbox name="MemImp" value="Nil|Working memory|Short term|Recent|Remote|Particular events|Confabulates|Amnesiac"]

-- Relating --

Eye contact: [select value="Normal|Fleeting|Avoidant|None|Staring"]
Facial expression: [select value="Responsive|Constricted|Tense|Anxious|Sad|Depressed|Angry"]
Attitude toward author: [select value="Cooperative|Dependent|Dramatic|Passive|Uninterested|Silly|Resistant|Critical|Hostile|Sarcastic|Irritable|Threatening|Suspicious|Guarded|Defensive|Manipulative|Argumentative"]

-- Affect and Mood --

Affect: [select value="Appropriate|Labile|Restricted|Blunted|Flat"]
Mood: [select value="Euthymic|Anxious|Angry|Apathy|Ashamed|Prideful|Sad|Irritable|Hostile|Pessimistic|Depressed|Hypomanic|Euphoric"] -- [text name="field_name" default="other"]
Mood rated out of 10: [select value="Not rated|1|2|3|4|5|6|7|8|9|10"]

-- Thought and Language --

Speech flow: [select value="Normal|Mute|Loud|Blocked|Paucity|Pressured|Flight of ideas"]
Thought content: [select value="Congruent with mood and circumstances|Incongruent Congruent with mood and circumstances|Personalizations|Persecutions|Indecisions|Suspicions|Delusions|Ideas of reference|Ideas of influence|Illusions"]
Thought organisation: [select value="logical and goal directed|Circumstantial|Tangential|Loose associations|Flight of ideas|Neologisms|Blocking|Obsessive"]
Preoccupations: [select value="Nil|Phobias|Somatic|Suicide|Homicidal|Guilt|Religion"] - Other: [text name="field_name" default="Nil"]
Hallucinations: [select value="Nil|Auditory|Visual"]
Hallucination content: [text name="HalCon" default="N/A"]

-- Executive Functions --

Fund of knowledge: [select value="Average|Above average|Impoverished"]
Intellectual functioning: [select value="Average|Below average|Above average|Needs Assessment"]
Abstraction: [select value="Normal|Concrete|Functional|Popular|Abstract|Overly abstract"]
Judgment: [select value="Sound|Fair|Poor|Dangerous"]
Reality testing: [select value="Realistic|Adequate|Distorted|Variable|Unaware"]
Insight: [select value="Makes connections|Gaps|Occasional|Unaware|Nil|In denial"]
Decision making: [select value="Normal|Simplstic|Impulsive|Vacillates|Confused|Paralyzed"]

-- Current Stressors --

Stressors: [checkbox name="Stressors" value="Money|Housing|Family conflict|Work|Grief and loss|Illness|Transitions|Legal difficulties|Peer group|Relationship"]
Coping ability: [select value="Normal|Resilient|Exhausted|Overwhelmed|Deficient supports"]
Skill deficits: [checkbox name="SkillDefs" value="None|Education|Communication|Interpersonal|Decision making|Self control|Responsibility|Self care|Activities of daily living"]
Supports: [checkbox name="Supports" value="Self|Family|Friends|Parole officer|Church|NGO|GP"] Other: [text name="field_name" default="nil"]
Supports needed: [textarea name="field_name" default="No other supports needs at this time"]

-- Social Functioning --

Social maturity: [select value="Responsible|Irresponsible|Self-centered|Impulsive|Isolates"]
Social judgment: [select value="Normal|Street smart|Naive|Heedless|Victimized|Improper"]

-- Risk --

Suicide: [select value="no active suicidal ideation|Vague suicidal ideation|intense suicidal ideation|Has a suicide plan without intent|Has strong intent to suicide without plan|Has strong intent and a plan to suicide"]

-- Other Aspects of Mental Status --

[textarea name="field_name" default="Nothing to report"]

ASSESSMENT

Axis I:

[checkbox value="unable to rate|Schizophrenia Spectrum|Bipolar Disorder|Depressive Disorder|Anxiety Disorder|OCD|Trauma and Stress related Disorder|Dissociative Disorder|Somatic Symptom related|Feeding and Eating related|Elimination related|Sleep-Wake Disorder|Sexual Dysfunction|Gender Dysphoria|Impulse Control related|Substance related|Neurocognitive Disorder|Medically Induced|needing further assessment to clarify|Stress|Coping difficulties"]

Axis II:

[checkbox value="Paranoid (suspicious)|Schizoid (isolative)|Schizotypal (odd)|Antisocial (hostile)|Borderline (unstable)|Narcissistic (self-interested)|Avoidant (anxious)|Dependent (passive)|Obsessive-compulsive (controlling and rigid)"]

Axis III:

[checkbox value="Infection|Neoplasia|Endocrine|Nutritional|Metabolic|Immune system|Haematologic|Neurologic|Circulatory|Respiratory|Digestive|Genitourinary|Pregnancy / childbirth|Dermatological|Musculoskeletal|Connective tissue|Congenital abnormality|Perinatal|Medical problems NOS|No identified concerns"]

Axis IV:

[checkbox value="problems with primary support group|problems related to the social environment|education problems|occupation problems|housing problems|economic problems|problems with access to health care|legal problems|criminal problems|problems related to the environment|no identified concerns"]

Axis V:

Current GAF: [checkbox value="91 – 100 No symptoms. Superior functioning in a wide range of activities|81 – 90 Absent or minimal symptoms, good functioning in all areas|71 – 80 If symptoms are present, they are transient and expectable reactions to psychosocial stressors.|61 – 70 Some mild symptoms, but generally functioning pretty well.|51 – 60 Moderate difficulty in everyday functioning.|41 – 50 Serious impairment in everyday functioning.|31 – 40 Some impairment in reality testing or communication and major impairment in several areas.|21 – 30 Behaviour is considerably influenced by poor reality testing; an inability to function in almost all areas of life.|11 – 20 Some danger of hurting self or others; occasionally fails to maintain minimal personal hygiene; gross impairment in communication.|1 – 10 Persistent danger of severely hurting self or others; persistent inability to maintain minimal personal hygiene or serious suicidal act with clear expectation of death.|0 Inadequate information"]

Baseline GAF: [checkbox value="unable to rate|91 – 100 No symptoms. Superior functioning in a wide range of activities|81 – 90 Absent or minimal symptoms, good functioning in all areas|71 – 80 If symptoms are present, they are transient and expectable reactions to psychosocial stressors.|61 – 70 Some mild symptoms, but generally functioning pretty well.|51 – 60 Moderate difficulty in everyday functioning.|41 – 50 Serious impairment in everyday functioning.|31 – 40 Some impairment in reality testing or communication and major impairment in several areas.|21 – 30 Behaviour is considerably influenced by poor reality testing; an inability to function in almost all areas of life.|11 – 20 Some danger of hurting self or others; occasionally fails to maintain minimal personal hygiene; gross impairment in communication.|1 – 10 Persistent danger of severely hurting self or others; persistent inability to maintain minimal personal hygiene or serious suicidal act with clear expectation of death.|0 Inadequate information"]

MODIFIABLE FACTORS

[checkbox value="enhance mood|reduce psychosis Sx|decrease eating|increase eating|decrease ETOH|endure withdrawal of substances|distress tolerance|boost hope|improve sleep|tolerate distress|enhance self-efficacy|reduce pain|increase knowledge|increase assertiveness|motivate medical treatment|enhance problem solving|increase resilience|address distorted cognitions|treat medical concerns|medication adherence and compliance|enhance agency|strengthen ego functioning"]

FACTORS IMPACTING ON RECOVERY

[checkbox value="relationship problems|education problems|occupational|housing|debt|economic circumstances|social environment|victim of crime|legal problems|background of childhood adversity|history of victimization|unemployment|problems related to upbringing|medical problems|pregnancy|religious|discord with family|discord with most people|extreme beliefs|personality instability|lifecycle transition|substance misuse|low self-efficacy|sexual difficulties|medication adherence and compliance|psychological defenses|relationship problems|feeling hopeless|unaware of problem|denying the problem"]

STAGE OF CHANGE

[checkbox value="no awareness of the problem|pre-contemplation|contemplation|preparation|action|maintenance"]

MEDICATION (patient report)

[checkbox value="I haven't been prescribed any medication|I don't want to take it|I'm thinking about it|feels like the dose is too high|is working as intended|needs to be reviewed with the Dr|is not being taken as suggested|is not working as intended|is having unpleasant side effects|will need a repeat script"]

SUMMARY / IMPRESSION

[textarea cols=60 rows=30 default="

Patient presented to me complaining of CONCERNS.
Attributed to AXIS 1-4
This has resulted in GAF
The patient looked and sounded OBSERVATION
Although improved MODIFIABLE factors would help
Patient is at STAGE OF CHANGE, further complicated by FACTORS IMPACTING ON RECOVERY
Patient is compliant with medication, psychosocial supports and psychological interventions.
Progress on their CONCERNS is static, fair, good
Recovery could be enhanced through
"]

PLAN / ACTION

[checkbox value="further assessment|refer to other support services|referal declined|recommend supportive counselling|recommend insight oriented counselling|recommend CBT|recommend ACT|recommend psychoeducation|recommend reflective counselling|recommend psychotherapy|recommend behavioural modification|recommend parent training|recommend family therapy|recommend interpersonal effectiveness training|unsuitable for therapy"]

[textarea cols=60 rows=20 default=""]
PRESENTING CONCERNS

-- Emotional Distress --



-- Self-Esteem/Concept --



-- Relationship Concerns --

.

-- Life Transitions --



-- Physical Complaints --



-- Substance Abuse --



-- Self-Management --



-- Trauma --



-- Psychosocial Stresses --



-- Achievement --



-- Physical Complaint--



-- Indefinite --



-- Quality of Life --



PATIENT REPORT



NEUROVEG CONCERNS



OBSERVATION

-- Appearance and Self-Care --

Stature:
Weight: - Weight
Clothing:
Grooming:
Cosmetics:
Posture:
Motor activity:
Other noticeable aspects:

-- Sensorium --

Attention:
Concentration:
Orientation Impairment:
Memory Impairment:

-- Relating --

Eye contact:
Facial expression:
Attitude toward author:

-- Affect and Mood --

Affect:
Mood: --
Mood rated out of 10:

-- Thought and Language --

Speech flow:
Thought content:
Thought organisation:
Preoccupations: - Other:
Hallucinations:
Hallucination content:

-- Executive Functions --

Fund of knowledge:
Intellectual functioning:
Abstraction:
Judgment:
Reality testing:
Insight:
Decision making:

-- Current Stressors --

Stressors:
Coping ability:
Skill deficits:
Supports: Other:
Supports needed:

-- Social Functioning --

Social maturity:
Social judgment:

-- Risk --

Suicide:

-- Other Aspects of Mental Status --



ASSESSMENT

Axis I:



Axis II:



Axis III:



Axis IV:



Axis V:

Current GAF:

Baseline GAF:

MODIFIABLE FACTORS



FACTORS IMPACTING ON RECOVERY



STAGE OF CHANGE



MEDICATION (patient report)



SUMMARY / IMPRESSION



PLAN / ACTION



Result - Copy and paste this output:

Send Feedback for this SOAPnote

Your email address will not be published.

More SOAPnotes by this Author: