Posted: August 11th, 2023

SOAP Note for Psychiatric Diagnosis in Child or Teen

Please do SOAP ON PSYCHIATRIC diagnosis for child or teen and include component mention below
Include at list 2 reference within last 5 year

(In Units 2–9, you will choose one patient encounter to submit a Follow-up SOAP note for review.
Please see the template provided to guide your writing of SOAP notes.
Follow the rubric to develop your SOAP notes for this term.
The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple, and complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.)

SOAP Note Components:
• Chief Complaint
• HPI
• Past Psychiatric History
• Age of manifestations of symptoms
• Previous Diagnoses and when they were diagnosed
• Psychotropic History
• All psychotropic medications
• Why stopped
• How long they were on
• Adherence
• Suicide Attempt/Homicidal Ideation History
• Legal History
• Trauma History
• Substance Use History
• Address
• Tobacco
• Alcohol
• Abuse of Prescription Drugs or Illicit Substances
• Length of time used substances
• Last Use
• Sobriety
• Detox/Rehab history
• Withdrawal Symptom History
• Social History
• Where born and raised
• Parental history
• Married or divorced during childhood
• Relationship with parents during childhood and now
• Siblings
• How many and where they are in the order
• Any developmental issues
• Highest level of education
• Current employment status
• If on disability – list why they are on disability
• Relationship status
• Married
• Divorced
• Single
• Widowed
• Children
• Number
• Ages
• Relationship
• Living arrangements
• Who they live with
• Do they feel safe
• Past medical history/surgical history
• Family medical/psychiatric history
• Review of Systems/Physical Assessment
• Mental Status Exam
• Appearance
• Speech
• Mood
• Affect
• Thought Process
• Thought Content
• Cognition
• Insight
• Judgement
• Psychiatric Screening Tools if any are utilized during the appointment and their results (Example PHQ-9 is 21 and very difficult
• Diagnostic Tests Reviewed
• Make sure to include any pertinent results
• Laboratory results reviewed with patient, discussed abnormal Vitamin D level and treatment options
• If no issues with labs:
• Laboratory results reviewed with patient, no abnormal results noted
• Differential Diagnoses
• With rationale
• 3 are required
• Must Include ICD codes
• Definitive Diagnoses
• With rationale
• Must Include ICD Codes
• It’s rare that patient’s only have 1 diagnosis
• The number of diagnoses can affect your reimbursement as a provider

• Treatment Plan/Plan of Care
• One of the most important parts of the note
• Include the following
• Medication management
• Medication, Dose, Route, Time
• State Reason for the Medication (I will mark down if this is not included in the plan)
• State reason for any changes
• Discontinued Abilify related to side effects of weight gain
• Increase Lexapro to 10mg daily for depression and anxiety, if patient continues to have depressive symptoms may increase to 15mg at next appointment
• Decreased Seroquel to 100mg daily at bedtime for sleep as the patient c/o increased daytime fatigue
• Include a statement such as
• Risks, benefits and side effects were discussed in-depth with the patient.
• Patient’s medications were eprescribed and sent to the patient’s designated pharmacy
• Include any diagnostics that were ordered at this appointment
• Complementary and Alternative Approaches
• Include referral for therapy
• Include type of therapy and why you are recommending
• Example
• Patient was referred for EMDR due to history of trauma
• Patient was referend for DBT due to history of borderline personality disorder
• Include any type of referrals for anyone else and why
• It is recommended that the patient follow-up with PCP for any medical issues.
• Will refer patient out for neuropsychological examination for cognitive decline
• Include Follow-Up appointment
• Include CPT Codes for visit
• Review billing guidelines for medical complexity and time
• If you are billing for time, make sure you include why it took that much time
• See Billing and Coding Presentation from APA about new billing and coding procedures for 2023.
• See presentation slides attachment for reference

Levels of Medical Decision Making
Levels of medical decision making will have four levels comprised of three elements:
1. Number of Complexity of Problems Addressed
2. Amount and/or Complexity of Data to be Reviewed and Analyzed
3. Risk of Complications and/or Morbidity or Mortality of Patient Management.
To qualify for a particular level of medical decision making and code at that level, a minimum of two of the three elements for that level of medical decision making must be met or exceeded.
Time
Time reporting may be used for selecting the level of Evaluation and Management service whether or not counseling or coordination of care dominates the service. Time is calculated as the total time spent personally by the provider on the date of the encounter, including both face-to-face and non-face-to-face time.
CPT Code Total Time
99202 15-29 mins
99203 30-44 mins
99204 45-59 mins
99205 60-74 mins
99211 0-9 mins
99212 10-19 mins
99213 20-29 mins
99214 30-39 mins
99215 40-54 mins

There are two built-in timers in Elation’s visit note that Provider level users can use to track their time on the day of an encounter. The timers are named Time with patient and Time documenting and are only visible to users who are logged in with provider-level accounts.

Please do psychiatric SOAP note for patient of any age with inpatient psychiatric diagnosis /condition

Include at list 2 reference within last 5 year

Patient Name: XXX BL
MRN: XXX 77/M/ WHITE

Date of Service: 0

Start Time: 10:00 End Time: 10:54

Billing Code(s): 90213, 90836
(be sure you include strictly psychotherapy codes or both E&M and add on psychotherapy codes if prescribing provider visit)

Accompanied by: Brother

CC: follow-up appt. for counseling after discharge from inpatient psychiatric unit 2 days ago

HPI: 1 week from inpatient care to current partial inpatient care daily individual psychotherapy session and extended daily group sessions

S- Patient states that he generally has been doing well with depressive and anxiety symptoms improved but he still feels down at times. He states he is sleeping better, achieving 7-8 hours of restful sleep each night. He states he feels the medication is helping somewhat and without any noticeable side-effects.
Crisis Issues: He states he has no suicide plan and has not thought about suicide since the recent attempt. He states has no access to prescription medications, other than the fluoxetine. He believes the classes he participated in while inpatient have helped him with coping mechanisms.
Reviewed Allergies: NKA
Current Medications: Fluoxetine 10mg daily
ROS: no complaints

O-
Vitals: T 98.4, P 82, R 16, BP 122/78
PE: (not always required and performed, especially in psychotherapy only visits)
Heart- RRR, no murmurs, no gallops
Lungs- CTA bilaterally
Skin- no lesions or rashes
Labs: CBC, lytes, and TSH all within normal limits

Results of any Psychiatric Clinical Tests: BAI=34

MSE:
Gary Davis, a 36-year-old white male, was disheveled and unkempt on presentation to the outpatient office. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age. During the interview, he was attentive and calm. He was impatient, but polite in his interactions with this examiner. Mr. Davis reported that today was the best day of his life, because he had decided he was going to be better and start his own company. His affect was labile, but appropriate to the content of his speech (i.e., he became tearful when reporting he had “bogeyed number 15” in gold yesterday). His speech was loud, pressured at times then he would quickly gain composure to a more neutral tone. He exhibited loosening of associations and flight of ideas; he intermittently and unpredictably shifted the topic of conversation from golf, to the mating habits of geese, to the likelihood of extraterrestrial life. Mr. Davis described grandiose delusions regarding his sexual and athletic performance. He reported no auditory hallucinations. He was oriented to time and place. He denied suicidal and homicidal ideation. He refused to participate in intellectual- or memory-related portions of the examination. Reliability, judgment, and insight were impaired.

A – with (ICD-10 code)
Differential Diagnoses:
1. choose 3 differential diagnoses
2.
3.
Definitive Diagnosis:
Major Depressive Disorder, recurrent, without psychotic features F33.4
Generalized Anxiety Disorder F41.1

P- Continue Fluoxetine increasing dose to 20mg.

Continue outpatient counseling: partial inpatient program continued with individual and group sessions

Non-pharmacological Tx: Psychotherapy Modality used: CBT
Pharmacological Tx: (be specific and give detailed Rx information)
Education: discussed smoking cessation
Reviewed medication side effects and adherence importance
Follow-up: in one week or earlier if any depressive symptoms worsen.
Referrals: none at this time

_________________________________-
SOAP Note for Psychiatric Diagnosis in Child or Teen

Patient Name: [Patient’s Name]
MRN: [Medical Record Number]
Age: [Age]
Gender: [Gender]
Date of Service: [Date]

Chief Complaint:
The patient presents for a psychiatric evaluation with concerns of behavioral and emotional difficulties.

HPI:
The patient’s parents report that over the past several months, they have noticed significant changes in their child’s behavior. The patient has been experiencing frequent episodes of sadness, irritability, and social withdrawal. They also note a decline in academic performance and a loss of interest in previously enjoyed activities. The patient has been experiencing difficulty sleeping and has lost appetite resulting in weight loss. There have been no recent significant life events or stressors. The parents express concern for their child’s well-being and request a psychiatric evaluation.

Past Psychiatric History:
The patient has no previous history of psychiatric diagnoses or treatment.

Age of Manifestations of Symptoms:
Symptoms began approximately [duration] ago.

Previous Diagnoses and Dates of Diagnosis:
There are no previous psychiatric diagnoses.

Psychotropic History:
The patient has not been on any psychotropic medications in the past.

Suicide Attempt/Homicidal Ideation History:
There is no history of suicide attempts or homicidal ideation.

Trauma History:
The patient denies any history of traumatic events.

Substance Use History:
The patient denies any history of substance use.

Social History:
The patient was born and raised in [location]. They have a supportive family environment with both parents present. There are no significant family or developmental issues reported. The patient is currently attending school and is in [grade level]. They have no employment history.

Mental Status Exam:

Appearance: The patient appears [appropriate for age, well-groomed].
Speech: The patient’s speech is [normal rate, fluent].
Mood: The patient reports feeling [sad, irritable].
Affect: The patient’s affect is [congruent with mood].
Thought Process: The patient’s thought process is [logical, coherent].
Thought Content: No delusions or hallucinations are reported.
Cognition: The patient is alert and oriented to person, place, and time.
Insight: The patient demonstrates limited insight into their symptoms.
Judgment: The patient’s judgment is fair.
Diagnostic Tests Reviewed:
No specific diagnostic tests were reviewed during this encounter.

Differential Diagnoses:

Major Depressive Disorder, single episode (ICD-10 code: F32.0)
Generalized Anxiety Disorder (ICD-10 code: F41.1)
Definitive Diagnoses:

Major Depressive Disorder, single episode (ICD-10 code: F32.0)
Generalized Anxiety Disorder (ICD-10 code: F41.1)
Treatment Plan/Plan of Care:

Psychotherapy: The patient will be referred for cognitive-behavioral therapy (CBT) to address the symptoms of depression and anxiety.
Education: The patient and their family will receive psychoeducation regarding depression and anxiety, including coping strategies and self-care techniques.
Close monitoring: The patient will have regular follow-up appointments to assess treatment response, medication adherence, and overall well-being.
Referral: No additional referrals are warranted at this time.
Follow-Up Appointment:
The patient is scheduled for a follow-up appointment in [timeframe] to assess treatment response and make any necessary adjustments to the treatment plan.

CPT Codes for Visit: [Insert appropriate CPT codes based on the level of medical decision making and time spent during the visit]

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Study Notes & Homework Samples: Self-assessment of your financial literacy »Psychotherapy With Multiple Modalities