General SOAP Outline for UK Psychiatry Inpatient
S: Brief paragraphs about how patient felt and did yesterday & this morning from
patient’s words, and utilize the nursing report & interview time as much as possible.
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How feeling, sleep, eating, meds, etc
Impression of whether the patient is improving or worsening
O: Vital signs.
MSE: (mental status exam)
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Appearance --- grooming (unshaven, clean, clothing), manner (cooperative,
pleasant, difficult), eye contact (good, poor), psychomotor activity
State of consciousness --- alert, confused…
Affect --- your observation on pt’s mood (depressed, hypomanic, agitated,
neutral), range of motion (full, blunted, constricted, flat), whether the patient is
stable (stable & labile)
Mood --- Pt’s description of on how they feel
Attitude
Speech --- normal, fast, pressed, slow, long pause
Thought process --- logical vs. illogical, coherent vs. incoherent, attentions,
stream
Thought contents --- suicidal ideation (SI), homicidal ideation (HI), thoughts of
hurting his/herself, audio/visual hallucinations (AVH, with descriptions)
Insight --- good, fair, poor
Judgement --- good, fair, poor
Labs and Meds if necessary
A: Axis I
Axis II
Axis III
Axis IV
Axis V
--- current psy diagnosis
--- Personality disorder, mental retardation (IQ < 70)
--- current/ chronic medical conditions
--- Psychosocial & environment stressors
--- GAF (0-100)
P: Treamtments…