SOAPisanacronymthatstandsforSubjective.docx
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.
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S =
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Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/
Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS)
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O =
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Objective data: Medications; Allergies; Past medical history; Family psychiatric history;
Past surgical history; Psychiatric history, Social history; Labs and screening tools;
Vital signs; Physical exam, (Focused), and Mental Status Exam
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A =
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Assessment: Primary Diagnosis and two differential diagnoses including ICD-10
and DSM5 codes
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P =
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Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools
, patient/family teaching, referral, and follow up
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Other: Incorporate current clinical guidelines or , research articles, and the role of the PMHNP in your evaluation.
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Reminder: It is important that you complete this assessment using your critical thinking skills. You are expected to synthesize your clinical assessment, formulate a psychiatric diagnosis, and develop a treatment plan independently. It is not acceptable to document "my preceptor made this diagnosis." An example of the appropriate descriptors of the clinical evaluation is listed below. It is not acceptable to document “within normal limits.”
AAPC Admin. (2013, August 1). Successfully capture HPI elements in psychiatry E/M notes. Advancing the Business of Healthcare. https://www.aapc.com/blog/25848-successfully-capture-hpi-elements-in-psychiatry-em-notes/
Submission Instructions:
· Upload your completed Comprehensive Psychiatric Evaluation as a word document. It will be assessed through Turnitin.
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