[comment memo=" This SOAP stands for Situation Observations Assessment Plan.
SITUATION is why you are having contact with the patient. If they are a voluntary patient, then it is ALWAYS at their request. If they are an involuntary patient, this can be modified to reflect their legal obligation. If they are voluntary but lack capacity then it is always at the request of the guardian.
Frame the situation in terms of a clinical concern the Pt is having, that they are requesting support with. Try not to frame it as being clinician led or clinician centered.
If this is a psychotherapy session, state it clearly here.
For example: I met with Jane at her request, because she wanted clinical support with her persistent low mood, which has led to missing a lot of school.
Try to avoid clinician led notes such as: I met with Jane to offer her CBT in the context of depression."]
[textarea cols=60 rows=10 default="Contact with the patient at XXXX, as the patient is requesting support with XXXX, which causes difficulties with XXXX"]
[comment memo="OBSERVATIONS is the MSE section, but it is also where you put all observed evidence to support your ASSESSMENT.
Work through the MSE systematically but also feel free to add collateral information, things you observe in a patients home, old patient notes, comments from others etc.
For instance, aside from the MSE, you can add environmental observations and collateral reports: patients house was in disarray, furniture overturned, trash overflowing, cigarettes scattered on the floor. Patients sister told me 'he isnt taking his meds'. Patients neighbour advised 'he was in the street yelling all night'
If its a psychotherapy session, include observations about the therapy. For example: the patient was able to engage in the cognitive reframing exercises and reported feeling better as a result"]
Pt is a [checkbox value="male|female"] [checkbox value="young adult|mid-aged adult|older adult|young teen|older teen|child"]. [checkbox value="Reasonably|Not well|Meticiulously"] kempt, looks [checkbox value="average weight|overweight|underweight"].
Posture: [checkbox value="relaxed|rigid|ill-at-ease|stooped|confident|aggressive|tense|slumped|unable to rate"]
Movement: [checkbox value="unremarkable|odd / peculiar|slowed|repetitive|restless|agitated|tremorous|unable to rate"]
Attention: [checkbox value="no concerns - attended well|seemed unaware|inattentive|distractible|hyper-vigilant|scattered concentration|preoccupied|confused|focused on irrelevancies"]
Engagement: [checkbox value="no concerns - warm, chatty, and engaged well|avoided eye contact|fixed staring|glaring at author|tense facial expression|dependent and needy|dramatic and exaggerating concerns|passive and difficult to engage|uninterested|silly and joking around|resistant|critical and verbally combative|hostile and threatening|sarcastic and taunting|irritable|fatuous|flirtatious|demanding|threatening|guarded|paranoid|defensive and resistant|cold, aloof and inaccessible|manipulative|argumentative"]
Mood reported: [text default=""]
Affect observed: [checkbox value="mainly euthymic|tearful|labile|restricted|blunted |flat|dysphoric|anxious|angry |apathetic|ashamed|prideful|sad|irritable|hostile|pessimistic|depressed|manic|euphoric|unable to rate"]
Speech: [checkbox value="spontaneous|normal RTV|abnormal RTV|clear and articulate|selectively mute|mute|loud|laconic|verbose|quiet|pressured|rambling|babbling|incongruent with mood and current circumstances|mute - unable to rate"]
Thinking: [checkbox value="logical|linear|rigid and concrete|personalizing|persecutory|indecisive|unrealistic|difficulties of reference|magical ideas of influence|distorted|pseudologica fantastica|memory difficulties|provided unnecessary detail (circumstantial)|wandered between many topics (tangential)|jumped from one idea to another (loose associations)|racing thoughts (flight of ideas)|abruptly changed topic or stopped mid-sentence (thought blocking)|tended to loop or repeat themes (obsessive)|stuck on over-valued ideas (preoccupations)|unable to rate"]
Orientation: [checkbox value="no concerns|AH reported|VH reported|poor judgement|poor reality testing|poor insight|complete denial|unable to rate"]
Stressors disclosed without prompting: [checkbox value="nil|self-esteem|parenting|mental illness Sx|spouse|money|school|physical health|energy|sleep|body weight\shape|eating|food|housing|employment|mood|family|work|grief and loss|illness|transitions|legal|peers|relationship"]
Suicide risk: [select value="denied active suicidal ideation when asked|vague suicidal ideation|intense suicidal ideation|has a suicide plan without strong intent|has strong intent to suicide without a plan|has strong intent and a plan to complete suicide|unable to rate"].
[textarea cols=60 rows=30 default="Collateral information:"]
[comment memo="ASSESSMENT is where you assess the patient through a clinical lens. The lens is the model or framework of understanding, whether it be a social work, medical, or psychological frame.
If the session is a psychotherapy session you can assess the patients response to the therapy and their recovery progress. Make sure the ASSESSMENT is based clearly on the OBSERVATIONS and must capture the SITUATION.
For example, if the SITUATION was: I met with Jane at her request, because she wanted clinical support with her persistent low mood, which has led to missing a lot of school -- the ASSESSMENT must assess this.
For example: Jane looks moderately depressed. She is frequently tearful, she is sleeping poorly, and not eating much according to mum, because of enormous sadness about her boyfriend suddenly breaking up with her 4 weeks ago. Today she sounded flat and talked in a low monotone, which mum says is not her usual self. She has missed 2 weeks of school so far and so her depression is having an enormous impact. She reported she cant go to school because her ex is in most of her classes. I offered to work with her around feelings of guilt towards her boyfriend. However, we were not able to accomplish much today as Jane did not feel like talking to me."]
Impression of current mental health symptoms: [checkbox value="stable|improved|worsening|unable to rate"]
[textarea cols=60 rows=30 default=""]
[comment memo="PLAN is where you make logical plan based on all the above information, remembering to keep it patient led.
For example: When asked if she would like to continue with psychotherapy for her low mood she gave an unenthusiastic 'I suppose'. When asked if she would like a number to call in a crisis and a worksheet with distraction techniques she agreed and I provided them. When asked if she would like an appointment with the psychiatrist next week to explore medication options she agreed.
Try to avoid clinician led plans: the patient would benefit from CBT for depression. I have urged her to consider talking to me nore next time. She should ideally take medication and I will encourage this"]
[textarea cols=60 rows=30 default=""]
Next apt [textarea cols=30 rows=1 default=""]
Result - Copy and paste this output: