Describe history of present illness, including analysis of symptoms

Students will be required to complete one SOAP (psych) note on a patient seen in the practicum setting each week. These need to follow the guidelines for writing SOAP notes (S = Subjective, O = Objective, A = Assessment, P = Plan) and include relevant history, physical findings, assessment, and interventions.

Student is required to submit a minimum of one SOAP note in order to receive grade.

Please use bipolar manic type as or depression as diagnosis



Student Name: __________________________________Patient Initial______

Patient Information

􀁸 Gender

􀁸 Height and Weight

􀁸 Marital status

􀁸 Occupation

􀁸 Current medication

􀁸 Past Psychiatric medication

􀁸 Allergies


􀁸 Chief complaint: describe the reason for the visit and chief complaint

􀁸 Describe history of present illness, including analysis of symptoms

􀁸 Medical history

􀁸 Psychiatric history (age of onset, diagnosis, previous treatments, hospitalization)

􀁸 Family history

􀁸 Psychosocial/Developmental History

􀁸 Substance Use History

􀁸 Current or Past Legal History

􀁸 Current or Past Truma

􀁸 Current or Past Abuse

􀁸 Review of Systems (no significant issues revealed, CV, Renal, GI, Hepatic, CNS, GU, CA, Metabolic, Pulm, GYN, HIV)


􀁸 Mental Staus exam

􀁸 Screening tests/symptom scales Performed

􀁸 Strengths/Limitations

􀁸 Include any objective data you have now, including labs


􀁸 Identify diagnosis, including differential diagnosis and rationale

􀁸 Case Formulation


􀁸 List plan of care, including medication (Evidence Based Practice) and rationale

􀁸 Describe any needed lab work with rationale

􀁸 Identify alternatives to this plan

􀁸 Referrals

􀁸 How soon should the patient return for follow-up and why?

􀁸 Was this patient an appropriate patient for a nurse practitioner? Is a nurse practitioner the

appropriate provider of follow-up care for this patient?

􀁸 Was this a health care encounter that required consultation or collaboration with another

health care provider?

􀁸 If yes, to whom should the patient be referred? Is this type of provider available in the



􀁸 What education does this patient/family need?

􀁸 What community resources are available in the provision of care for this client?

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