Follow-up Psychiatric Visit SOAP

Date & Attendees

[Today's date] [Attendee list, name and relationships]

Reason For Visit

[Brief statement indicating reason for visit. - Use the simple present tense "presented" rather than the present perfect tense "has presented"] (Do not include follow-up details here, only the primary complaint.)

Best Hopes

[Identify the patient's best hopes for the session or treatment outcomes, in the present tense.] (Focus on solution-focused brief therapy concepts.)

Current Medications & Adherence

[List current medications in a numbered list - insert "adherence confirmed for all medications" at the end of the section on a new line.] (Include the class of medication after each drug name, e.g., antidepressant, antipsychotic, etc. Combine medication list and adherence comments here. each on a separate line)

Substance Use

[Insert current substance use if relevant - otherwise, "No substance use reported"]

History of present illness

Break down this section into paragraphs, each paragraph addresses a new concern or idea that was discussed. [Since the last visit, [patient's first name] has experienced changes in symptoms including [specific symptoms or changes]. These symptoms have been present for [duration] and occur with a frequency of [frequency], with a severity level described as [severity]. The patient reports that the symptoms are influenced by [mention any modifying factors], noting that [what makes symptoms better or worse]. Additionally, the patient has experienced associated symptoms, such as [any other symptoms]. These symptoms have impacted the patient's daily life, including [describe effect on school, home, social interactions].]

Psychiatric History

[Narrative of persistent positive symptoms and daily functioning. Include any facilities (by name, if available) or workplace issues the patient has reported previously here.] (Place General and Psychiatric history at the top of this section.)

Metabolic Monitoring

[HR(sitting), BP (sitting) (both on a single line), HR(standing), BP (standing) (both on a single line) height, weight, Waist circumference, BMI, etc.] (each on a separate line)

Rating Scales and Investigations

PHQ-9: [score] GAD-7: [score] PRS (Psychosis Rating Scale): [score]

Objective

Mental Status Examination: Orientation: [State orientation to time, place, and person.] Appearance & Behavior: [Describe grooming, dress, cooperation, and specific behaviors such as restlessness or tremors.] Speech: [Describe rate, tone, and volume.] Mood: [Patient's described mood.] Affect: [Describe congruence, range, and capacity for engagement.] Thought Process: [Describe logic and linearity.] (Note absence of formal thought disorder if applicable.) Thought Content: [Describe dominant themes, anxiety, or worry.] (Note suicidal ideation status here.) Perception: [Describe perceptual disturbances.] (Specifically note if patient denies hearing voices or seeing things.) Cognition: [Assess memory and attention.] (Place after perception. Focus on memory, not orientation.) Insight & Judgment: [Assess insight into illness and judgment capabilities.]

Assessment

[Summary of the patient's diagnosis, stability, and key clinical findings.]

Safety plan

[Assess any risks or safety concerns, such as suicidal ideation or self-harm. Confirm a safety plan if needed.]

Patient education

[Educate the patient and parents on coping strategies and any changes in the treatment plan. Discuss lifestyle modifications, such as sleep hygiene, diet, and exercise.]

Plan

New interventions: [Any new therapeutic recommendations] Biological: [List medication adjustments, monitoring plans, and referrals. (in a numbered list)] Psychological: [Describe therapy recommendations, educational materials, and behavioral strategies.] Ongoing therapy: [e.g., Cognitive Behavioral Therapy (CBT), play therapy; progress and compliance; Social-Cultural: [Encourage social connections, community resources, and provide reassurance.]

Follow-up

[Next follow-up visit. Case worker follow-up visit.]