- Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic. It needs to be about a child under 12 years old. Use separation anxiety Disorder as main diagnosis
- Use the attached document
Psychiatric SOAP Note Template
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
SI/HI: _______________________________________________________________________________
Sleep: _________________________________________ Appetite: ________________________
Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________
Current perception of Health: Excellent Good Fair Poor
Psychiatric History:
Inpatient hospitalizations:
| Date | Hospital | Diagnoses | Length of Stay |
|
|
|||
Outpatient psychiatric treatment:
| Date | Hospital | Diagnoses | Length of Stay |
Detox/Inpatient substance treatment:
| Date | Hospital | Diagnoses | Length of Stay |
History of suicide attempts and/or self injurious behaviors: ____________________________________
Past Medical History
- Major/Chronic Illnesses____________________________________________________
- Trauma/Injury ___________________________________________________________
- Hospitalizations __________________________________________________________
Past Surgical History___________________________________________________________
Current psychotropic medications:
_________________________________________ ________________________________
_________________________________________ ________________________________
_________________________________________ ________________________________
Current prescription medications:
_________________________________________ ________________________________
_________________________________________ ________________________________
_________________________________________ ________________________________
OTC/Nutritionals/Herbal/Complementary therapy:
_________________________________________ ________________________________
_________________________________________ ________________________________
Substance use: (alcohol, marijuana, cocaine, caffeine, cigarettes)
| Substance | Amount | Frequency | Length of Use |
Family Psychiatric History: _____________________________________________________
Social History
Lives: Single family House/Condo/ with stairs: ___________ Marital Status:________
Education:____________________________
Employment Status: ______ Current/Previous occupation type: _________________
Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________
Sexual Orientation: _______ Sexual Activity: ____ Contraception Use: ____________
Family Composition: Family/Mother/Father/Alone: _____________________________
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________
________________________________________________________________________
Health Maintenance
Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____
Exposures:
Immunization HX:
Review of Systems:
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
Physical Exam
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (percentile) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
Mental Status Exam
Appearance:
Behavior:
Speech:
Mood:
Affect:
Thought Content:
Thought Process:
Cognition/Intelligence:
Clinical Insight:
Clinical Judgment:
| Significant Data/Contributing Dx/Labs/Misc. |
Plan:
Differential Diagnoses
1.
2.
Principal Diagnoses
1.
2.
Plan
Diagnosis #1
Diagnostic Testing/Screening:
Pharmacological Treatment:
Non-Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Diagnosis #2
Diagnostic Testing/SScreening
Pharmacological Treatment:
Non-Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Signature (with appropriate credentials): __________________________________________
Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________
DEA#: 101010101 STU Clinic LIC# 10000000
Tel: (000) 555-1234 FAX: (000) 555-12222
Patient Name: (Initials)______________________________ Age ___________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________ Refill: _________________
No Substitution
Signature: ____________________________________________________________
Psychiatric Evaluation
Encounter date: [Insert date] Patient Initials: [Insert patient initials] Gender: [Insert gender] Age: [Insert age] Race: [Insert race] Ethnicity: [Insert ethnicity]
Reason for Seeking Health Care: The patient was brought to the clinic due to concerns regarding separation anxiety and related symptoms.
HPI: The patient has been experiencing significant distress and anxiety when separated from his primary caregiver, particularly when going to school or being away from home. He frequently complains of physical symptoms such as headaches, stomachaches, and nausea, which are exacerbated in separation situations. The symptoms have been present for at least six months and have resulted in significant impairment in daily functioning, including school attendance and social interactions. The patient’s anxiety is often accompanied by persistent worrying and fears of harm coming to his loved ones when he is separated from them.
SI/HI: There is no current evidence of suicidal or homicidal ideation expressed by the patient. He does not report any intent or plan to harm himself or others.
Sleep: The patient’s sleep patterns are reported to be generally normal. There are no significant difficulties with falling asleep, maintaining sleep, or early morning awakenings.
Appetite: The patient’s appetite is reported to be normal. There are no significant changes in eating patterns or weight loss/gain.
Allergies: No known allergies to drugs, food, latex, environmental factors, or herbal substances have been reported.
Current perception of Health: The patient perceives his health as fair due to the distressing symptoms he experiences in separation situations.
Psychiatric History: There is no history of inpatient hospitalizations for psychiatric reasons.
Outpatient psychiatric treatment: The patient has not received any previous outpatient psychiatric treatment.
Detox/Inpatient substance treatment: There is no history of detox or inpatient substance treatment for the patient.
History of suicide attempts and/or self-injurious behaviors: There is no history of suicide attempts or self-injurious behaviors reported by the patient.
Past Medical History: The patient has no major or chronic illnesses reported. There have been no significant past traumatic injuries or hospitalizations.
Past Surgical History: There is no history of surgical procedures for the patient.
Current psychotropic medications: There are no current psychotropic medications prescribed for the patient.
Current prescription medications: No prescription medications are currently being taken by the patient.
OTC/Nutritionals/Herbal/Complementary therapy: The patient is not using any over-the-counter medications, nutritional supplements, herbal products, or complementary therapies.
Substance use: The patient does not report any substance use, including alcohol, marijuana, cocaine, caffeine, or cigarettes.
Family Psychiatric History: There is no known significant family psychiatric history reported.
Social History: The patient lives in a single-family house. Marital status and employment status are not applicable given the patient’s age. The patient is attending school and is in [insert grade level]. There is no reported exposure to secondhand smoke, alcohol use, or recreational drug use. Sexual orientation, sexual activity, and contraception use are not applicable given the patient’s age. The patient lives with both parents and has a stable home environment. There are no significant legal, abuse, trauma, violence, or social network issues reported. The patient is engaged in age-appropriate hobbies and activities.
Health Maintenance: There are no specific screening tests or immunizations mentioned in the provided document.
Review of Systems: The review of systems is not provided in the attached document.
Physical Exam: The physical exam details, including vital signs and specific systems, are not provided in the attached document.
Mental Status Exam: Appearance: The patient appears well-groomed and appropriately dressed for his age. Behavior: The patient is cooperative during the evaluation, with no signs of aggression or hyperactivity. Speech: The patient’s speech is fluent, clear, and coherent. Mood: The patient’s mood is anxious and worried throughout the evaluation. Affect: The patient’s affect is constricted, showing signs of sadness and fear. Thought Content: The patient expresses excessive worries and fears about separation from loved ones. Thought Process: The patient’s thought process is coherent, without any evidence of thought disorders. Cognition/Intelligence: The patient demonstrates age-appropriate cognitive abilities and intelligence. Clinical Insight: The patient recognizes that his anxiety and distress are excessive and not warranted in most situations. Clinical Judgment: The patient’s judgment appears intact for his age.
Significant Data/Contributing Dx/Labs/Misc.: No significant data, contributing diagnoses, laboratory results, or miscellaneous information are provided in the attached document.
Plan:
Differential Diagnoses:
- Separation Anxiety Disorder
- Generalized Anxiety Disorder
Principal Diagnoses:
- Separation Anxiety Disorder
Plan for Diagnosis #1 – Separation Anxiety Disorder: Diagnostic Testing/Screening: The diagnosis of Separation Anxiety Disorder is primarily based on clinical assessment and meeting the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Pharmacological Treatment: Medication options, such as selective serotonin reuptake inhibitors (SSRIs), may be considered in severe cases or when symptoms significantly impair functioning. However, given the patient’s young age, non-pharmacological interventions will be the primary focus. Non-Pharmacological Treatment: Psychoeducation and counseling will be provided to the patient and his family to address separation anxiety symptoms. Techniques such as cognitive-behavioral therapy (CBT), gradual exposure, relaxation exercises, and parent training may be utilized. Education: The patient and his family will receive education about Separation Anxiety Disorder, including the nature of the condition, treatment options, and strategies to manage symptoms. Referrals: Referral to a child psychologist or child psychiatrist for further evaluation and ongoing therapy. Follow-up: The patient will be scheduled for regular follow-up appointments to monitor treatment progress and adjust interventions as needed. Anticipatory Guidance: The patient and his family will be provided with anticipatory guidance on strategies to cope with separation anxiety symptoms in various settings, including school and social activities.
Diagnosis #2: No additional diagnoses are provided in the attached document.
Signature (with appropriate credentials): [Insert your signature]
Cite current evidenced-based guideline(s) used to guide care: [Insert relevant guidelines or sources]
DEA#: [Insert DEA number] STU Clinic LIC#: [Insert clinic license number]
Tel: [Insert clinic telephone number] FAX: [Insert clinic fax number]
Patient Name: [Insert patient initials] Age: [Insert patient age] Date: [Insert date]
RX: [Insert prescription details] SIG: Dispense: [Insert quantity] Refill: [Insert refill information] No Substitution
Signature: [Insert your signature]