PROGRESS (SOAP) NOTES:

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PROGRESS (SOAP) NOTES:
Date and Time
Title: Psychiatry MS3 PN (name and pager here or at end of note)
Significant Events: Over past 24 hours
Subjective (S):
Use the patient’s own words as much as possible
 Vegetative symptoms (sleep, appetite, concentration/energy, anxiety, etc.)
 Patient’s complaints, pain, medication side effects
 Requests
Objective (O): ALSO LIST MEDS AND DOSES IN SIDE COLUMN




Vital Signs
Physical Exam (if pertinent, or new changes – rash, etc.)
Labs (admit labs of first day, new results, or new labs ordered)
Studies (CXR, ECG, US, neuropsychological testing, etc.)
MENTAL STATUS EXAM (MSE):
Appearance
Behavior
Speech
Mood
Affect
Thought Process
Thought Content
Insight
Judgment
Cognition
- describe hygiene, clothing and appropriateness, grooming
- posture, movement, psychomotor agitation/retardation, catatonia
- rate, rhythm, volume, prosody, latency, pressured, content (real words?)
- what the patient says, how they are feeling (put in “quotes”)
- your description of how patient feels
- organization, tight, linear, logical, perseverance, tangential, circumferential
- SI/HI, A/VH, delusions, paranoia, thought insertion, thought blocking,
special powers, grandeur, anxiety, flashbacks, nightmares, craving
- how well do they understand the situation? Poor, Fair, or Good
- how well is their decision making? Poor, Fair, or Good
- MMSE score, A&O x 3, grossly intact
Assessment (A): 1-2 sentence summary of
 Patient profile: age, M/F, race, occupation, marital status, significant characteristics (IVDU,
pregnant)
 Diagnosis (may include differential)
 Prognosis
 Treatment and tolerance / side effects/ improvement
 Diagnosis: Axis I, Axis II, Axis III
Plean (P):
List by diagnosis or problem (medication strategy, planned tests, social work issues,
discharge plans)
1. Major Depressive Disorder
1) Start Paxil 20 mg PO qd
2) Schedule outpatient appointment with Dr. Psychiatrist
3) Etc.
SIGN YOUR NAME (print name & pager #)
Have your resident read note and co-sign
Name:
MR #
Room:
Date:
ID:
CC:
HPI:
onset
duration/course
degree of impairment
psychological sxs:
psychosis: AH/VH
cognitive problems: memory
mood ∆s: irrit., depr., elation
causes
what makes it better
anyone else w/problem
how coping
how fix it
goals
SI/SA/HI
somatic sxs:
vegetative state
weight loss
insomnia
energy loss
anhedonia
pain, h/a
seizures, head trauma
PΨH:
HABITS:
Tobacco:
Rec.drugs/IVDA:
ETOH:
date started, amt.:
SHX:
Occupation:
Living Conditions:
Marital:
Military:
Education:
FHX:
Father:
Mother:
Brother:
Sister:
Allergies:
MSE:
General
Appearance/Hygiene:
Phy/Mental Age:
Attitude toward examiner:
Cooperative, irritated, seductive, guarded, defensive,
indifference, apathetic, sarcastic
Behavior:
Ψmotor:
EC:
Tics:
Activity: agitation, retardation, fighting
Speech:
Tone: pressured, resists interruption, expressive, slurred)
Rate: (rapid, low)
Volume: (loud, soft, hoarse)
Affect:
Subjective (euthymic, happy, sad, euphoric, SI, HI, guilty,
bored, anxious, irritable, agitated, panicky, terrified,
angry, enraged, sensual, flat, blunted/restricted, labile, full)
Range: (broad, limited)
Congruence: (appropriate, labile, superficial)
Mood:
PMH:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
MEDS:
Thought Process:
Logical, goal-oriented:train of thought cam be easily followed
Poverty of thought/speech: ↓ability/interest in interacting with
environment or answering questions
Flight of ideas: thoughts race ahead of ability to
communicate them
Thought blocking: abrupt cessation of communication
Loosening of Associationsns:illogical shifting between
unrelated topics
Tangential: Thought which wanders from original point
Circumstantial: Unnecessary digression which eventually
reaches patient
Echolalia: Echoing of words and phrases
Neologisms: New words invented by patient
Clanging: Speech based on sound such as rhyming and
punning rather than logical connections
Perservation: Repetition of phrases/words in the flow of speech
Ideas of Reference: Interpreting unrelated event as having
direct reference to patient such as TV talking to them
Rambling
Thought Content:
Preoccupations: phobias, paranoia, obsessions,
Compulsions
Delusions: nihilism, poverty, somatic distress, sin,
grandeur, reference (events apply to self), control
(force actions), persecution, erotomania
SI/SA, HI, thought/acts of violence
Impresssion:
Perception Disorders:
DSM-IV:
Hallucinations: False sensory perceptions: Auditory,
Visusal (delirium), Tactile, Gustatory, Olfactory
(seizure)
Illusions (misinterpretation of stimuli)
Depersonalization (fragmentation of self)
Derealization (world is not real, things alien and strange)
Broadcasting, thought insertion
Axis I:
Axis II:
Cognitive Function:
LOC: (hyperalert, alert, lethargic, stupor, coma)
Orientation: (person, place, time, situation)
Concentration: (sustained attention via serial 7’s/
months backward, requires repetition and
redirection, distracted
ST Memory: (remember “green, 13, Phil,” at time
0 & 5 minutes
Fund of Knowledge: Name past 5 presidents (Clinton,
Bush, Reagan, Carter, Ford)
Intelligence: (requires formal psychological testing)
Abstraction to test TP: (stitch in time saves 9; even
monkeys fall out of trees; the tongue is the enemy
of the neck; grass is always greener on the other
side of fence; don’t count your chickens until they
hatch; a golden hammer will knock down iron door)
Similarities: how is a tree and a fly alike?
Comprehension: story of man with golden brick,
Buried. Dug it out to look at it; it was stolen. Why
Not paint brick with gold paint?
Insight:
(awareness of illness, impact of illness on life,
expectations from hospitalization, goals)
Judgment:
(Manage finances, ADLs / IADLs, avoid danger,
“found a sealed, addressed, stamped envelope,”
“Kitchen is flooded and water running over the sink”)
PE:
Gen:
VS:
HEENT:
Head:
Eyes:
Ears:
Nose:
Oral:
Neck:
CV:
LUNGS:
ABD.:
SKIN:
EXT:
NEURO: CN II-XIL, 2/4 DTRs, Cerebellar, Gait
MS: ROM, 5/5 Strength
Axis III:
Axis IV:
Homelessness, poor social support, unemployed, chronic
mental illness
Axis V: GAF
Plan:
1.
2.
3.
4.
5.
6.
Admit to 1 NW, Green Team
Diagnosis
Status: voluntary or involuntary (hospital hold)
Condition: (good, stable, fair, guarded, critical)
Vitals: q shift, routine, q 15”
Diet: regular, ADA (diabetic), low sodium, clear liquid,
NPO
7. Activity: ad lib., strict bed rest, titrate to milieu per NCP
8. Allergies
9. Routine labs: Complete Metabolic Set: CBC,Chem 7
(CME vs BMS), TSH, Free T4, Y/A, UDS (3-cocaine,
MJ, Br, 4-&EtOH; 5-Barb), +/- VDRL/HIV
10. Medications
MVI 1po qd
MOM 30 cc po q6h prn constipation
Mylanta 30 cc po q6h prn dyspepsia
Tylenol 650 mg po q6h prn pain
Ativan (lorazepam) 1 mg po X1 dose now, then 1-2 mg
po/IM q6hours prn agitation. NTE 6 mg/24 hours
Inapsine 0.5 cc IM q 6 hours prn severe agitation.
NTE 6 mg / 24 hours (or Haldol 1-5 mg)
Trazadone 50-60 mg po qhs pm insomnia X one dose
for further insomnia (Zolpidern not on formulary)
11. Call HO SPG>175, DBP>95<55, HR>100<55,
R>24<&, T>38.3
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