General SOAP Template - Dr.Deepu

ASSESSMENT

[Summarize the patient's history and current presentation in a very concise format, including key psychological and behavioral patterns. highlight areas where psychoeducation or behavioral interventions may be beneficial. Include any relevant diagnoses or observations about the patient's mental health status.] [Highlight the patient's stage of change in a new line] Example: Pt with a hx of anxiety and depression exacerbated by rigid expectation of elimination of Sx with medication and poor behavioral activation, in the context of a pattern of disengagement and avoidance when stress is high. Pt will benefit from psycho education on appropriate role of medication ad behavioral methods and behavioral activation. Patient is in Preparation stage of change

Intervention type / Modality

[List the types of interventions or modalities used during the session in bullet point format. For example: Acceptance and Commitment Therapy (ACT), Behavioral Activation, Psychoeducation, etc.]

PLAN

[Outline the plan for follow-up care, medication adjustments, psychoeducation, and behavioral interventions. Include specific goals or actions the patient will take to address their symptoms.] For example: 1. F/U with BHC: [Follow-up plan, e.g., at next PCP visit] 2. Changes to Psychotropic Medication Regimen: [Details, e.g., per PCP] 3. Psychoeducation / Behavioral Intervention: [Details of psychoeducation provided, metaphors used, and behavioral strategies discussed.] a. [Specific psychoeducation provided, e.g., explanation of depressive and anxious cycles, patterns of avoidance, etc.] b. [Specific behavioral goals, e.g., setting a sleep routine, engaging in mindfulness exercises, etc.] c. [Additional behavioral goals, e.g., physical activity, relaxation techniques, etc.] 4. Treatment plan: [Details about the duration and scope of care, e.g., likely will not exceed 3 visits for this episode of care.] 5. Recommendation(s) to the Physician/PCP: [Specific recommendations for the PCP, e.g., (in bullet point format), follow-up on barriers, creating value-based action goals, etc.] Example: 1. F/U with BHC: At next PCP visit 2. Changes to Psychotropic Medication Regimen: Per PCP 3. Psychoeducation / Behavioral Intervention: Metaphors: Chinese finger trap: Focus on leaning in, stop struggling, acceptance and Empathy, validation, and reflective listening a. Provided psychoeducation on depressive and anxious cycle. Explored pattern of avoidance and disengagement and how that worsens sx. Illustrated this utilzing the chinese finger trap metaphor highlighting that the more one resists it will persist. Discussed engagement in value-based behaviors. b. He will set and stick to a sleep routine: wake up time 10:00-11:00 AM; no naps during the day c. He will play and engage in guided mindfulness, leaves on a stream, at bed time to self-manage anxious ruminations d. He will walk once a day for 30 minutes at mid-afternoon 4. Treatment plan: Likely will not exceed 3 visits for this episode of care. No Tx plan needed 5. Recommendation(s) to the Physician/PCP: 1. F/u and assess for barriers in implementing established goals 2. Can work towards creating specific value-based action goals at next visit

Introduction

Pt is a [age] year old [Male/Female] presenting with [Reason of visit] Today's visit: [Reason of visit]

Contextual Interview

- Living Situation: [Describe the current living situation, including who the individual lives with, any recent relocations, and reasons for moving.] - Relationship Status: [Detail the duration and quality of the individual's current relationship.] - Family Relationships:[Summarize the individual's relationships with family members and any relevant family history of mental health issues.] - Friends/Social Support: [Outline the individual's social support network and the impact of mental health on these relationships.] - Belief System: [Describe the individual's spiritual or religious beliefs and practices.] - Current Work/Income: [Provide details about the individual's current employment status, past job experiences, and any impact of mental health on work.] - Mental Health History: [Narrate the individual's history with anxiety and depression, including triggers, symptoms, management strategies, and past treatments.] - Activities: [List current and past hobbies, interests, and barriers to engagement.] - Substance Use: [Detail the individual's use of caffeine, nicotine, alcohol, marijuana, and other substances.] - Nutrition: [Describe the individual's eating habits and any changes related to mental health.] - Physical Activity: [Summarize the individual's current level of physical activity and any aspirations for increased activity.] - Sleep: [Detail the individual's sleep patterns, difficulties, and any related mental health impacts.] - Values: [Identify the individual's core values, such as career and family.] - Other Relevant Social/Cultural History: [Include any additional relevant history, such as ADHD diagnosis, past treatments, and current concerns to discuss with healthcare providers.]

OBJECTIVE

[Document objective observations about the patient during the visit, including orientation, engagement, speech, mood, and behavior. Include any screening measures, time spent with the patient, and interpreter use if applicable.] For example: - Referred by: [Referring provider] - Orientation: [Patient's orientation status, e.g., oriented x4] - Engagement: [Patient's engagement level, e.g., engaged in visit] - Speech: [Speech characteristics, e.g., WNL] - Mood: [Mood characteristics, e.g., congruent with behavior] - Screening Measures: [Details about any screening tools used, e.g., PHQ-9, GAD-7, and their scores.] For example: - Referred by: [Referring provider] - Orientation: [Patient's orientation status, e.g., oriented x4] - Engagement: [Patient's engagement level, e.g., engaged in visit] - Speech: [Speech characteristics, e.g., WNL] - Mood: [Mood characteristics, e.g., congruent with behavior] - Screening Measures: [Details about any screening tools used, e.g., PHQ-9, GAD-7, and their scores.] - Time spent face-to-face with patient: [Duration of the visit] - Interpreter used: [Yes/No] - Additional Notes: [Details about the patient's consent and understanding of care within the clinic.] Example: Referred by: PCP Pt oriented x4, engaged in visit, speech WNL, mood congruent with bx. Depressed and appropriately tearful Screening Measures: PHQ-9 score of Not assessed falls in N/A GAD-7 score of Not assessed falls in N/A Time spent face-to-face with patient: 45 minutes Interpreter used: no The patient was informed of the following characteristics of their care within the UT Health RGV Multi-Speciality Clinic on Jackson: a) Behavioral health providers operate as consultants to the medical team and not as stand-alone providers of care. b) All information discussed with team members as applicable/appropriate will be documented in the shared electronic health record and visible by all care team members. Patient consented to meet with BHC.