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 Clinical Notes 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. 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. 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. 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. CG&AM&BF_10/10/18 Criteria Exemplary Exceeds Expectations Advanced Meets Expectations Intermediate Needs Improvement Novice Inadequate Total Points Quality of Initial Post Provides clear examples supported by course content and references. Cites three or more references, using at least one new scholarly resource that was not provided in the course materials. All instruction requirements noted. 40 points Components are accurate and thoroughly represented, with explanations and application of knowledge to include evidence-based practice, ethics, theory, and/or role. Synthesizes course content using course materials and scholarly resources to support important points. Meets all requirements within the discussion instructions. Cites two references. 35 points Components are accurate and mostly represented primarily with definitions and summarization. Ideas may be overstated, with minimal contribution to the subject matter. Minimal application to evidence-based practice, theory, or role development. Synthesis of course content is present but missing depth and/or development. Is missing one component/requirement of the discussion instructions. Cites one reference, or references do not clearly support content. Most instruction requirements are noted. 31 points Absent application to evidence-based practice, theory, or role development. Synthesis of course content is superficial. Demonstrates incomplete underst ...

1. 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
Clinical Notes
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.
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.
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.
Plan

2. 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.
CG&AM&BF_10/10/18
Criteria
Exemplary
Exceeds Expectations
Advanced
Meets Expectations
Intermediate
Needs Improvement
Novice
Inadequate
Total Points
Quality of Initial Post
Provides clear examples supported by course content and
references.
Cites three or more references, using at least one new scholarly
resource that was not provided in the course materials.
All instruction requirements noted.
40 points
Components are accurate and thoroughly represented, with
explanations and application of knowledge to include evidence-

3. based practice, ethics, theory, and/or role. Synthesizes course
content using course materials and scholarly resources to
support important points.
Meets all requirements within the discussion instructions.
Cites two references.
35 points
Components are accurate and mostly represented primarily with
definitions and summarization. Ideas may be overstated, with
minimal contribution to the subject matter. Minimal application
to evidence-based practice, theory, or role development.
Synthesis of course content is present but missing depth and/or
development.
Is missing one component/requirement of the discussion
instructions.
Cites one reference, or references do not clearly support
content.
Most instruction requirements are noted.
31 points
Absent application to evidence-based practice, theory, or role
development. Synthesis of course content is superficial.
Demonstrates incomplete understanding of content and/or
inadequate preparation.
No references cited.
Missing several instruction requirements.
Submits post late.

4. 27 points
40
Peer Response Post
Offers both supportive and alternative viewpoints to the
discussion, using two or more scholarly references per peer
post. Post provides additional value to the conversation.
All instruction requirements noted.
40 points
Evidence of further synthesis of course content. Provides
clarification and new information or insight related to the
content of the peer’s post.
Response is supported by course content and a minimum of one
scholarly reference per each peer post (minimum of two).
All instruction requirements noted.
35 points
Lacks clarification or new information. Scholarly reference
supports the content in the peer post without adding new
information or insight.
Missing reference from one peer post.
Partially followed instructions regarding number of reply posts.
Most instruction requirements are noted.
31 points
Post is primarily a summation of peer’s post without further
synthesis of course content.
Demonstrates incomplete understanding of content and/or

5. inadequate preparation.
Did not follow instructions regarding number of reply posts.
Missing reference from both peer posts.
Missing several instruction requirements.
Submits post late.
27 points
40
Frequency of Distribution
Initial post and two peer posts made on three separate days.
All instruction requirements noted.
10 points
Initial post and two peer posts made on two separate days.
8 points
Minimum of two post options (initial and/or peer) made on two
separate days.
7 points
All posts made on same day.
Submission demonstrates inadequate preparation.
No post submitted.
6 points
10
Organization
Well-organized content with a clear and complex purpose
statement and content argument. Writing is concise with a

6. logical flow of ideas
5 points
Organized content with an informative purpose statement,
supportive content, and summary statement. Argument content
is developed with minimal issues in content flow.
4 points
Poor organization and flow of ideas distract from content.
Narrative is difficult to follow and frequently causes reader to
reread work.
Purpose statement is noted.
3 points
Illogical flow of ideas. Prose rambles. Purpose statement is
unclear or missing.
Demonstrates incomplete understanding of content and/or
inadequate preparation.
No purpose statement.
Submits assignment late.
2 points
5
APA, Grammar, and Spelling
Correct APA formatting with no errors.
The writer correctly identifies reading audience, as
demonstrated by appropriate language (avoids jargon and
simplifies complex concepts appropriately).
Writing is concise, in active voice, and avoids awkward
transitions and overuse of conjunctions.

7. There are no spelling, punctuation, or word-usage errors.
5 points
Correct and consistent APA formatting of references and cites
all references used. No more than two unique APA errors.
The writer demonstrates correct usage of formal English
language in sentence construction. Variation in sentence
structure and word usage promotes readability.
There are minimal to no grammar, punctuation, or word-usage
errors.
4 points
Three to four unique APA formatting errors.
The writer occasionally uses awkward sentence construction or
overuses/inappropriately uses complex sentence structure.
Problems with word usage (evidence of incorrect use of
thesaurus) and punctuation persist, often causing some
difficulties with grammar. Some words, transitional phrases,
and conjunctions are overused.
Multiple grammar, punctuation, or word usage errors.
3 points
Five or more unique formatting errors or no attempt to format in
APA.
The writer demonstrates limited understanding of formal written
language use; writing is colloquial (conforms to spoken
language).
The writer struggles with limited vocabulary and has difficulty
conveying meaning such that only the broadest, most general

8. messages are presented.
Grammar and punctuation are consistently incorrect. Spelling
errors are numerous.
Submits assignment late.
2 points
5
Total P
Week 4 Discussion 1: Psychosis Case Study
Follow the steps to complete this discussion:
1. Watch the Video
2. Using the readings and references, write a treatment note for
this patient following the Psychiatric SOAP Note Template
(Word). Include a prescriptive decision in your case. What
medication would you choose? Why? If you do not choose to
medicate, why? What is your starting dose? How would you
decide to titrate dose, if appropriate? What labs would be
required? When? This is your opportunity to practice
prescribing and it is important that you give it a try and then
discuss those decisions and compare with your peers.
3. Organize your SOAP Note as follows:
· Subjective: Reported assessment data. Patient’s Psychiatric
and Medical History, and Patient’s Family Psychiatric History.
· Objective: Observed assessment data (include MSE and lab
findings).
· Assessment: Diagnostic impression. Identification of target
symptoms. Your thoughts about the case and an explanation of
your proposed decision making.
· Plan: Your plan of care. Include prescriptive decisions,
laboratory monitoring and recommended screenings and non
pharmacologic interventions like psychotherapy.

9. 4. Submit your treatment plan (P of SOAP note) to this
discussion forum by Day 5.
5. Submit your complete Psychiatric SOAP note for grading to
the Week 4 Assignment: Psychosis Case Study.
6. Consider the points on the grading rubric when writing your
note.
https://youtu.be/ZB28gfSmz1Y