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please write out this care plan and use the 2 ones below, reword and edit.complete a SOAP Note (Word) for the patient you worked with. (Note: The template is meant to be a guide. You can change the formatting of your SOAP note if the table style does not work for you. Additionally, you can copy and paste what you have written in iHuman into your SOAP note if the content is appropriate.)Your SOAP note should be no more than five pages long.Use academic sources, cited in APA format, to support your rationale in your Assessment and Plan.
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Psychiatric SOAP Note Template
There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective,
Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to
develop your style of SOAP in the psychiatric practice setting. Refer to the Psychiatric SOAP
Note PowerPoint for further detail about each of these sections.
Criteria
Subjective
Include chief
complaint, subjective
information from the
patient, names and
relations of others
present in the
interview, and basic
demographic
information of the
patient. HPI, Past
Medical and
Psychiatric History,
Social History.
Clinical Notes
Patient Information: EH, 15-year-old, Caucasian female
CC: “I am concerned about my daughter’s weight loss and excessive
exercising.”
HPI: EH presents with her mother for evaluation related to concerns
pertaining to intentional weight loss that began a year ago, which she
now deems has become concerning. Mom reports EH has lost 30
pounds over the past 12 months, 20 pounds of which she has lost
during the last six months. EH admits to restricting her
caloric/carbohydrate intake, binging and purging, abusing laxatives,
and exercising three to four hours a day. Moreover, EH reports
anxiety related to her “supposed” weight issue and a desire to lose
five more pounds.
Current Medications: None at present time
Allergies: NKDA
Past Medical History
Metatarsal stress fracture (March 2019)
Childhood obesity
No hospitalizations
CG&AM&BF_10/10/18
Surgical History: Unremarkable
Social History
Full-time high school student (straight A student)
Lives with mother
Denies alcohol and recreational drug use
Heterosexual, not sexually active at present time, not involved in a
relationship
Family History
Unremarkable psychiatric history other than cousin with eating
disorder
Objective
This is where the
“facts” are located.
Include relevant labs,
test results, vitals, and
Review of Systems
(ROS) – if ROS is
negative, “ROS
noncontributory,” or
“ROS negative with
the exception of…”
Include MSE, risk
assessment here, and
psychiatric screening
measure results.
ROS
ROS negative with the exception of:
Constitutional: 30-pound intentional weight loss/12 months, (+)
fatigue
Gastrointestinal: Denies abdominal pain, blood, or coffee ground
emesis (+) constipation
Genitourinary: Denies dysuria, frequency, or hematuria. LMP:
“maybe three months ago,” irregular menses, denies pregnancy, not
sexually active
Neurological: Fainted once during volleyball game, attributes to
heat. Denies headache, dizziness, ataxia, numbness or tingling in the
extremities
CG&AM&BF_10/10/18
Psychiatric: Denies history of depression, anxiety, or eating disorder
EXAM
VS: weight 100 pounds, 5’ 7” BMI 15.7 temp, 95.9, pulse oximetry
99% (unable to figure out how to obtain remainder of VS)
Mouth: Cracked lips, mild angular stomatitis
Skin, hair, nails: Lanugo, dry, rough skin, abrasions and calluses on
dorsa of right hand
Cardiac: Orthostatic hypotension (I was not able to take vitals but
noted this finding in case study)
Gastrointestinal: Abd lean, non-distended, (+) BS x 4, non-tender, no
organomegaly
OBJECTIVE
VS: weight 100 pounds, 5’ 7” BMI 15.7 temp, 95.9, pulse oximetry
99% (unable to figure out how to obtain remainder of VS)
Mouth: Cracked lips, mild angular stomatitis
Skin, hair, nails: Lanugo, dry, rough skin, abrasions and calluses on
dorsa of right hand
Cardiac: Orthostatic hypotension (I was not able to take vitals but
noted this finding in case study)
Gastrointestinal: Abd lean, non-distended, (+) BS x 4, non-tender, no
organomegaly
MSE
CG&AM&BF_10/10/18
Appearance: Thin, emaciated, young lady, dressed in loose attire.
Rough skin and thin hair. Abrasions and calluses are noted on the
dorsa of her right hand. Initially reserved but able to establish good
rapport towards the end of examination.
Behavior/Activity: Fidgety throughout the consultation
Speech: Spontaneous, normal rate, tone, and flow
Thought form: Logical and goal directed
Thought content: Glorified ideas on her weight. Although she is
preoccupied with the fear of being overweight, she does not exhibit
an obsession. No hallucinations or delusions are noted.
Mood: Mild dysphonia
Affect: Reactive
Suicidal Ideation: None
Homicidal Ideation: None
Orientation: A/O x 3
Memory: Immediate, recent, and remote memory intact
Judgment/Insight: Poor, does not recognize weight loss to be a
problem but nonetheless she is willing to participate in treatment
Attention/Concentration: Intact
SCREEINGS
EAT-26 > 20 (positive for eating disorder evaluation)
HAM-D: Not resulted
DIAGNOSTICS
CG&AM&BF_10/10/18
12 lead EKG: Borderline sinus bradycardia: Rate 60
T-wave flattening, ST depression, and QT prolongation
CMP: hypokalemia 3.2
Phosphorus, magnesium, HCG, TSH, TFT: WNL
Assessment
Include your findings,
diagnosis and
differentials (DSM-5
and any other medical
diagnosis) along with
ICD-10 codes,
treatment options, and
patient input regarding
treatment options (if
possible), including
obstacles to
treatment.
DIAGNOSIS
Anorexia nervosa, binge eating/purging type, F50.02
DSM-5 criteria for anorexia nervosa, binge eating/purging type
includes the following:

restriction of energy intake relative to physiologic
requirements

overwhelming fear of putting on weight or becoming
overweight, or persistent behavior that impedes weight gain,
although already at a significantly low weight

body image perception disturbance or persistent lack of
awareness of the gravity of
actual low BMI
engagement in self-induced vomiting or laxative misuse over
previous three months (American Psychiatric Association,
2013).
CG&AM&BF_10/10/18
Moreover, EH presented with the following clinical signs, which are
common to individuals suffering from anorexia nervosa:

amenorrhea

bradycardia (borderline)

brittle nails and fine hair

hypokalemia

lanugo
significant weight loss (Harrington, Jimerson, Haxton, &
Jimerson, 2015).
OBSTACLE(S) TO TREATMENT

Poor self-esteem

Limited peer support system

Poor judgment/insight, does not grasp gravity of current
situation as she continues to insist on losing five more
pounds.
Plan
Include a specific
plan, including
medications & dosing
& titration
considerations, lab
work ordered,
referrals to psychiatric
and medical
providers, therapy
recommendations,
holistic options and
CG&AM&BF_10/10/18
PLAN
APA criteria for inpatient admission for anorexia nervosa includes
the following:

heart rate less than 50 beast/minute during the day and 45
beats/minute during the night
complimentary
therapies, and
rationale for your
decisions. Include
when you will want to
see the patient next.
This comprehensive
plan should relate
directly to your
Assessment.

systolic blood pressure less than 90

orthostatic changes in pulse or blood pressure

arrhythmia

temperature less than 96 °F

less than 75% ideal body weight or continued weight loss
regardless of intensive therapy

refusal to eat

outpatient treatment failure (Campbell & Peebles, 2014).
Although I was not able to fully calculate EH’s vital signs due to my
inexperience with the iHuman program, I feel that she eseentially
meets criteria to be admitted to the hospital based on her clinical
presentation and poor insight and judgement.
References
American Psychiatric Association. (2013). Diagnostic and statistical
manual of mental disorders (5th ed.). Washington, DC:
American Psychiatric Publishing.
Campbell, K., & Peebles, R. (2014, September). Eating disorders in
children and adolescents: States of the art review. Pediatrics,
134(3). Retrieved from
https://pediatrics.aappublications.org/content/134/3/582
Harrington, B. C., Jimerson, M., Haxton, C., & Jimerson, D. C.
(2015, January). Initial evaluation, diagnosis, and treatment of
CG&AM&BF_10/10/18
anorexia nervosa and bulimia nervosa. American Family
Physician, 1(91), 46-52. Retrieved from
https://www.aafp.org/afp/2015/0101/p46.html
CG&AM&BF_10/10/18
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Psychiatric SOAP Note – Week 7
Criteria
Subjective
Include chief
complaint, subjective
information from the
patient, names and
relations of others
present in the
interview, and basic
demographic
information of the
patient. HPI, Past
Medical and
Psychiatric History,
Social History.
Clinical Notes
Ms. Eliza Henderick is a 16-year-old female who presents today with
her mother due to her mother’s concern for her weight loss, even
though the patient does not see this as a problem. Patient passed
out last week at volleyball and patient’s mother is concerned.
Patient’s mother was present throughout examination, with patient’s
consent.
History of Present Illness: Patient reports a 30-pound weight loss in
the past 12 months, with 20 pounds lost in the past 6 months.
Patient has been preoccupied with restricting her food intake,
participating in excessive exercising multiple times daily,
experimenting with weight loss medication, binge-eating, selfinduced vomiting, and use of laxatives for constipation. Patient
reports body-image distortions and anxiety of her appearance to
others. Patient denies pain. Patient reports being tired. Pt states
appetite and BM are normal. Patient passed out one week ago and
states it was from dehydration, denies further symptoms or problems
related to this incident. Patient states her periods have been
irregular or scant. Patient’s mother states patient strives to be a
perfectionist and patient states she has withdrawn from social
interactions to focus on her sports and academic activities.
Current Health Status:
Patient has no known drug, food or environmental allergies and does
not take any medication. Patient is not sexually active. All
immunizations are up to date. Patient reports no ETOH, recreational
drugs, smoking intake. Patient is able to complete activities of daily
living without assistance. No recent travel outside the country.
Current Mental Status: Patient denies any mental health complaints.
Denies suicidal/homicidal ideations. Denies hallucinations and
delusions. Denies extreme mood changes with highs and lows.
Past Medical History:
Patient reports she is in good health, denies past major illnesses,
hospitalizations, or surgeries Pt reports a metatarsal stress fracture
3 months ago, and syncopal episode 1 week ago.
Social History: Patient is a single high school student with good
grades and involved in extracurricular activities. No religious or
cultural considerations. Patient’s parents are divorced (x 1 year ago)
and her and her siblings spend time between both parents’ homes.
Patient’s relationship with her parents are good, feels that her
mother is overacting about her weight loss, eating and exercise
choices.
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Family History
Patient’s mother denies family illness – medical, psychiatric,
substance abuse. Both parents are alive, healthy. Patient has 2
sisters, alive and healthy.
Objective
This is where the
“facts” are located.
Include relevant labs,
test results, vitals, and
Review of Systems
(ROS) – if ROS is
negative, “ROS
noncontributory,” or
“ROS negative with
the exception of…”
Include MSE, risk
assessment here, and
psychiatric screening
measure results.
Vital Signs: BP: 90/60. Brachial Pulse: 68 Heart Rate: 60
Respirations: 16 Temperature 95.9 SpO2: 99% Weight: 100 lb.
Height: 5-07 BMI: 15.7
16-year-old emancipated female, alert and oriented to person, place,
in no apparent distress. Patient reluctant but cooperative, fidgety
clean, dressed in loose clothing.
Focused exam for chief complaint: Alert and oriented. Good eye
contact, speech is clear with normal rate, tone, and flow. Mood is
mildly dysphoric. Thought is logical, goal directed. Knowledge and
abstract thinking is good. Memory is intact for past and current
recall.
Review of systems:
General: No complaints of chest pain, dyspnea, dizziness. Denies
SOB, cough. No change in urinary elimination, BM, rectal bleeding.
Skin: warm, dry, rough, lanugo body hair, abrasions & calluses on
dorsum of right hand
HEENT: cracked lips, angular stomatitis, yellow colored
teeth/erosion with visible caries, dry/thin scalp hair
Neck: Bilaterally enlarged parotid glands
Breasts: Negative for focus assessment
Respiratory: Negative for focus assessment
Cardiovascular: Negative for focus assessment
Musculoskeletal: reduce muscle bulk for age/height
Urinary: Negative for focus assessment
Genital: Amenorrhea, Tanner Stage 4
Vascular: Negative for focus assessment
Neurological: negative except for stance stooped, small-step gate
with slight shuffle
Hematologic: Negative for focus assessment
Endocrine: Negative for focus assessment
Psychiatric: Does not recognize weight loss and excessive
exercising to be a problem, body-image distortion, preoccupied with
food, binging, purging, laxative misuse, food restriction, anxiety of
other’s perception of body, loss of social interest, perfectionist traits
for sports/academics
Psychiatric testing:
MDQ mood disorder questionnaire conducted – negative.
Hamilton rating scale for depression conducted.
Eating Attitudes Test conducted – likely/high risk.
CMP, magnesium serum, phosphorus serum, TFT, CBC, hCG
completed: resulted in WBC low, RBC low, Hcg low, Hct low,
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neutrophils low, monocytes low, potassium low, chloride low, carbon
dioxide high, chloride low
12 lead ECG completed: T-wave flattening, ST depression, QT
prolongation
HR: borderline sinus bradycardia. Bradycardia and hypotension is
common among patients presenting with anorexia nervosa and is
prevalent in up to 95% of these patients (Mehler & Brown, 2015)
MHS Assessments. (2018).
Assessment
Include your findings,
diagnosis and
differentials (DSM-5
and any other medical
diagnosis) along with
ICD-10 codes,
treatment options, and
patient input regarding
treatment options (if
possible), including
obstacles to
treatment.
Findings: 20 pound weight loss over 6 months, BMI below 16, weight
is less than expected for development of age/sex, fear of gaining
weight, purging/binging episodes over past 3 months, laxative
misuse, body-image disturbance (perceives self as fat, unhappy with
current body appearance), mirror gazing, loss of interest, fatigue,
behavior consistent with excessive weight loss & reduction of
calories, restricting food intake, excessive exercise, secondary
amenorrhea (not specific to DSM 5 criteria), borderline sinus
bradycardia, T-wave flattening, ST depression, GT prolongation,
WBC low, RBC low, Hcg low, Hct low, neutrophils low, monocytes
low, potassium low, chloride low, carbon dioxide high, chloride low –
indicating metabolic alkalosis, hypokalemia, and hypochloremia.
MDQ negative, Eating Attitudes Test conducted – likely/high risk.
Diagnosis: Anorexia Nervosa (307.1), binge eating/purging type,
(F50.02) severe (American Psychiatric Association, 2013)
Differential Diagnosis:
1. Social anxiety disorder (300.23/F40.10) (American Psychiatric
Association, 2013)
2. Major depressive disorder (296.2) (American Psychiatric
Association, 2013)
3. Hyperthyroidism (E05.9) (“2019 ICD-10-CM diagnosis code
E05.90,” 2019)
4. Anorexia nervosa: restricting type (307.1/F50.01) (American
Psychiatric Association, 2013)
5. Bulimia nervosa (307.51/F50.8) (American Psychiatric
Association, 2013)
As the treating PMHNP, I would discuss the appropriate treatment
for the patient – outpatient, inpatient, partial inpatient for psychiatric
care of anorexia nervosa, and the patient’s feelings about which
treatment option is appropriate. Dependent on the patient’s medical
needs and referral for medical evaluation for medical complications
related to anorexia nervosa. The patient will need nutritional
reinforcement first and foremost, starting with refeeding. Monitor for
abnormalities with electrolytes, metabolic, cardiac, endocrine,
hematology, musculoskeletal systems during this time. Monitor
patient’s daily calorie intake and exercise and provide education on
patient’s eating, exercise, and medical conditions. Offer
psychotherapy for patient through individual, group and family
therapies, with cognitive behavioral therapy, with the primary
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emphasis on cognitive restructuring being the primary recommended
type of psychotherapy recommended (Sansone, Levitt, &
Sansone, 2005). Patient should be offered medication as indicated
for treating anorexia nervosa, typically the medication of choice is an
SSRI (Sadock, Sadock, & Ruiz, 2015). Monitor the patient for
comorbidities that are prevalent with anorexia nervous, such as
depression and social phobias.
Plan
Include a specific
plan, including
medications & dosing
& titration
considerations, lab
work ordered,
referrals to psychiatric
and medical
providers, therapy
recommendations,
holistic options and
complimentary
therapies, and
rationale for your
decisions. Include
when you will want to
see the patient next.
This comprehensive
plan should relate
directly to your
Assessment.
Diagnostic: GAD 7, Oneome, CMP, magnesium serum, phosphorus
serum, TFT, CBC, LFT, estradiol, hCG, Eating Attitudes Test,
Suicide Assessment, and Hamilton Depression Rating
Pharmacologic: Fluoxetine 60 mg by mouth every morning. Patient
will be referred to hospitalization program for electrolyte replacement
and balancing. Collaborate with hospitalization team for multi-vitamin
and Vitamin D daily. If Patient is L methylfolate deficient, recommend
active L methylfolate replacement daily.
Non-Pharmacologic: Psychotherapy – individual, group, family,
meditation, journaling, weight restoration, acupuncture
Education: Provide information on nutrition, exercise, medical
conditions, signs and symptoms related to anorexia nervosa, SSRI
specific education including black box warning of suicide risk,
possible symptoms that can be experienced, medications and
supplements that can cause interactions, taking 2-4 weeks to notice
a change after starting SSRI, informing all providers what
medications patient is taking and notification to provider before
starting a medication, weight changes from an SSRI, communication
and collaboration with the treating team.
Referral: Due to the complexity of medical and psychological
implications, anorexia nervosa requires a comprehensive treatment
plan (Sadock, Sadock, & Ruiz, 2015). Provider will refer patient to
partial hospitalization program utilizing a behavioral management
plan, individual psychotherapy, motivational interviewing, group
therapy, family therapy and education, patient supervised nutrition
program, laboratory monitoring for associated medical abnormalities
and follow up testing as indicated in nutrition program. This
hospitalization team will include: psychotherapists, eating disorder
recovery specialist case manager, dietician, medical provider,
mental health provided, and social worker. PMHNP will monitor
progress and collaborate with hospitalization team during patient
treatment and patient will continue follow up visits with PMHNP for
follow up.
Follow up: Patient to return in two weeks or sooner if symptoms do
not resolve or become worse in two weeks, for medical evaluation,
Eating Attitudes Test, Suicide Assessment, and Hamilton
Depression Rating Scale retesting
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References
2019 ICD-10-CM diagnosis code E05.90. (2019). Retrieved from
https://www.icd10data.com/ICD10CM/Codes/E00-E89/E00-E07/E05-/E05
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Arlington, VA: American Psychiatric Publishing.
Mehler, P., & Brown, C. (2015, March 31). Anorexia nervosa – medical complications. Journal
of Eating Disorders, 3. http://dx.doi.org/10.1186/s40337-015-0040-8
Sadock, B., Sadock, V., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences/clinical
psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.
Sansone, R., Levitt, J., & Sansone, L. (2005, February …
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