SOAP 5 sig_2

Patient reports things have been [select name="variable_1" value="getting better|getting worse|just about the same"] since the last visit.
Neurovegetative Symptoms: sleep is [select name="variable_2" value="Good|Fair|Poor|Terrible|Not discussed"]; appetite is [select name="variable_3" value="Good|Fair|Poor|Terrible|Not discussed"]; energy levels are [select name="variable_4" value="Good|Fair|Poor|Terrible|Not discussed"]; concentration is [select name="variable_5" value="Good|Fair|Poor|Terrible|Not discussed"].
[textarea name="variable_6" default="sample text"]
Alert and Oriented: [select name="variable_7" value="x4|x3|x2|x1"]
Appearance: [select name="variable_8" value="Appropriately dressed/well groomed|disheveled|inappropriately dressed|neglected"].
Attitude toward the therapist: [select name="variable_9" value="cooperative|guarded|suspicious|paranoid|paranoid|warm"].
Eye contact: [select name="variable_10" value="Good|Fair|Poor|Fleeting|Avoidant"].
Psychomotor activity: [select name="variable_11" value="retardation|agitation|none"].
Speech: [select name="variable_12" value="normal rate/normal volume|spontaneous|impoverished|pressured|aphasic|emotional|monotonous"].
Thought process: [select name="variable_13" value="linear, goal-directed, coherent|disorganized|incoherent|flight of ideas|racing thoughts|loose associations|perseverative|tangential|spontaneous"].
Thought Content: [text name="variable_14" default="sample text"].
Mood: [text name="variable_15" default="sample text"].
Affect: [select name="variable_25" value="congruent with mood, stable|blunted|flat|incongruent with mood"].
Perception: [select name="variable_16" value="No Hallucinations|Audio Hallucinations|Visual Hallucinations|Tactile Hallucinations|Olfactory Hallucinations|preocuppied with delusions|preocuppied with thoughts"].
Suicidal Ideation: [select name="variable_17" value="none present|passive ideation, no plans or intent|activally suicidal"].
Homicidal Ideation:[select name="variable_18" value="no homicidal ideation|current homicidal ideation"]
Insight: [select name="variable_19" value="good|fair|poor"].
Judgement: [select name="variable_20" value="good|fair|poor"]

[textarea name="variable_21" default="sample text"]

Patient was scheduled for an appointment on [text name="variable_22" default="sample text"].
Prognosis: At the time of writing, patient's prognosis is [select name="variable_23" value="good|fair|poor|uncertain"] and continued treatment is [select name="variable_24" value="recommended|not recommended|Cdsds"].
[textarea name="variable_1" default="sample text"]

Christopher L Wilson, LCSW
Behavioral Health Provider
312- 250-7027 pager
Patient reports things have been since the last visit.
Neurovegetative Symptoms: sleep is ; appetite is ; energy levels are ; concentration is .

Alert and Oriented:
Appearance: .
Attitude toward the therapist: .
Eye contact: .
Psychomotor activity: .
Speech: .
Thought process: .
Thought Content: .
Mood: .
Affect: .
Perception: .
Suicidal Ideation: .
Homicidal Ideation:
Insight: .


Patient was scheduled for an appointment on .
Prognosis: At the time of writing, patient's prognosis is and continued treatment is .

Christopher L Wilson, LCSW
Behavioral Health Provider
312- 250-7027 pager

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.77, 26 form elements, 81 boilerplate words, 3 text boxes, 3 text areas, 20 drop downs, 26 total clicks
Questions/General site feedback · Help Ticket

2 responses to “SOAP 5 sig_2”

  1. Connie Hicks says:

    I like the note.

    Can I have your permission to revise. If that is possible, I will need help making this happen.

    919-422-2359 – if someone can help me get started.

    • Mark Morgan says:

      You could make a copy and then modify it. Click on upper right hand corner where it says ‘View’. Select ‘Edit Markup’ and then ‘Duplicate’.

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: