Week 2: Psychiatric / Behavioral Encounter Note

Submit 1 Mini-SOAP note on a patient that you saw in clinic this week. Submit as a Word Document. See example template below for required format.

Review the rubric for more information on how your assignment will be graded.

Demographic Data

• Patient initial (one initial only), age, and gender must be Health Insurance Portability and Accountability (HIPPA) compliant.

Subjective

• Chief Complaint (CC)
• History of Present Illness (HPI) (symptoms) in paragraph format
• Past Medical History (PMH): Current problem-focused and document pertinent information only.
• Current Medications:
• Medication Allergies:
• Social History: For current problem-focused and document only pertinent information only.
• Family History: For current problem-focused and document only pertinent information only.
• Review of Systems (ROS) as appropriate:

Objective

• Vital signs
• Mental Status Exam
• Physical findings listed by body systems, not paragraph form.
• Patient Health Questionnaires, Screenings, and the results (PHQ-9, GAD 7, suicidal)

Assessment (Diagnosis/ICD10 Code)

• Include all diagnoses that apply to this visit.
• Include one differential diagnosis.

Plan

• Dx Plan (lab, x-ray)
• Tx Plan: (meds)
• Pt. Education, including specific medication teaching points.   
• Safety Plan       
• Referral/Follow-up

*Based on population focu