SOAP Notes in Pysch

  I have heard from a few friends that are finishing up school that the psych rotation is the most frustrating.  The biggest complaint that I have heard is that a lot of psych facilities (at leas in our state) still use a SOAP style of documentation which is rarely seen in the acute care setting anymore. 


  So lets review SOAP stands for subjective, objective, assessment and plan. In a Psych setting the subjective is what the patient tells you he or she is feeling. Objective data is what you see, is the patient clean or disheveled, what kind of affect are they displaying? Remember in this portion that you must not record any opinions, this is only what you have observed. The assessment portion is where you now take your objective data and use what you have seen to form an assessment of the patient. The planning phase is where you now lay out a plan of care to work with.


Here is a really basic SOAP note that I found on my computer from school:


S: Pt is requesting discharge and states “I’m done with this place” “I’m much better now and have gotten what I need from here” “My mania is much better now that they started me on that other med”

O: Alert and oriented x4 with a bright affect. Pt is well groomed, with a neat appearance in clothing, clean shaven and reports that he showered this morning.  Speech is clear with a normal rate, pt tends to ramble and is hyper-vocal. Thought is tangential at times but logically sequenced. Delusions are present, pt often refers to the “mission from God” that he is on. Appropriate eye contact, social with staff and some peers. Spent part of the morning walking around the unit pushing a peer in his wheelchair. Attended group activity but declined to participate. Denies any suicidal or homicidal ideations and is able to contract for safety. Good appetite, ate all of breakfast and lunch tray. Verbalizes a belief that medications do not work and the self medication is more effective. Vitals WNL

A: Pt remains delusional with no suicidal thoughts and mania is subsiding but not yet fully controlled as evidenced by the tendency to be hyper-vocal. Pt is avoiding working on issues and has expressed that he feels above his peers. Pt may be at risk for non-compliance of medication

P: Encourage Pt to participate in groups daily. Begin medication education with pt 1:1 and have doctor reinforce education. Continue with treatment plan

  This was not highly detailed as this was the first SOAP note done on the patient, but hopefully it will give any of you having a hard time with organizing your information a hand.  Remember SOAP notes don't need to be long, they are designed to pass on pertinent information about the patient to whoever else is reading the chart, keep it clean and concise.