SOAP note + 1 page summary that highlights the warning signs of suicidality in the patient and why you chose the treatment plan you choose in your SOAP Note.
Review the video case: Suicide assessment of Client with initially Subtle Warning Signs of Suicide
Complete a SOAP Note as if you were the psychotherapist in the video. Then write a one page summary that highlights the warning signs of suicidality in the patient and why you chose the treatment plan you choose in your SOAP Note.
SOAP Template:
Patient Name: XXX
MRN: XXX
Date of Service: 01-27-2020
Start Time: 10:00 End Time: 10:54
Billing Code(s): 90213, 90836
(be sure you include strictly psychotherapy codes or both E&M and add on psychotherapy codes if prescribing provider visit)
Accompanied by: Brother
CC: follow-up appt. for counseling after discharge from inpatient psychiatric unit 2 days ago
HPI: 1 week from inpatient care to current partial inpatient care daily individual psychotherapy session and extended daily group sessions
S- Patient states that he generally has been doing well with depressive and anxiety symptoms improved but he still feels down at times. He states he is sleeping better, achieving 7-8 hours of restful sleep each night. He states he feels the medication is helping somewhat and without any noticeable side-effects.
Crisis Issues: He states he has no suicide plan and has not thought about suicide since the recent attempt. He states has no access to prescription medications, other than the fluoxetine. He believes the classes he participated in while inpatient have helped him with coping mechanisms.
Reviewed Allergies: NKA
Current Medications: Fluoxetine 10mg daily
ROS: no complaints
O-
Vitals: T 98.4, P 82, R 16, BP 122/78
PE: (not always required and performed, especially in psychotherapy only visits)
Heart- RRR, no murmurs, no gallops
Lungs- CTA bilaterally
Skin- no lesions or rashes
Labs: CBC, lytes, and TSH all within normal limits
Results of any Psychiatric Clinical Tests: BAI=34
MSE:
Gary Davis, a 36-year-old white male, was disheveled and unkempt on presentation to the outpatient office. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age. During the interview, he was attentive and calm. He was impatient, but polite in his interactions with this examiner. Mr. Davis reported that today was the best day of his life, because he had decided he was going to be better and start his own company. His affect was labile, but appropriate to the content of his speech (i.e., he became tearful when reporting he had “bogeyed number 15” in gold yesterday). His speech was loud, pressured at times then he would quickly gain composure to a more neutral tone. He exhibited loosening of associations and flight of ideas; he intermittently and unpredictably shifted the topic of conversation from golf, to the mating habits of geese, to the likelihood of extraterrestrial life. Mr. Davis described grandiose delusions regarding his sexual and athletic performance. He reported no auditory hallucinations. He was oriented to time and place. He denied suicidal and homicidal ideation. He refused to participate in intellectual- or memory-related portions of the examination. Reliability, judgment, and insight were impaired.
A – with (ICD-10 code)
Differential Diagnoses:
1. choose 3 differential diagnoses
2.
3.
Definitive Diagnosis:
Major Depressive Disorder, recurrent, without psychotic features F33.4
Generalized Anxiety Disorder F41.1
P- Continue Fluoxetine increasing dose to 20mg.
Continue outpatient counseling: partial inpatient program continued with individual and group sessions
Non-pharmacological Tx: Psychotherapy Modality used: CBT
Pharmacological Tx: (be specific and give detailed Rx information)
Education: discussed smoking cessation
Reviewed medication side effects and adherence importance
Follow-up: in one week or earlier if any depressive symptoms worsen.
Referrals: none at this time
Grading Rubic:
|
Assignment Criteria |
Level III |
Level II |
Level I |
Not Present |
|
Criteria 1 |
Level III Max Points Points: 8 |
Level II Max Points Points: 6.4 |
Level I Max Points Points: 4.8 |
0 Points |
|
Subjective Information |
1. Complete and concise summary of pertinent information. |
1. Well organized; partial but accurate summary of pertinent information (>80%). |
1. Poorly organized and/or limited summary of pertinent information (50%-80%); information other than “S” provided. |
1. Does not meet the criteria |
|
Assignment Criteria |
Level III |
Level II |
Level I |
Not Present |
|
Criteria 2 |
Level III Max Points Points: 8 |
Level II Max Points Points: 6.4 |
Level I Max Points Points: 4.8 |
0 Points |
|
Objective Information |
1. Complete and concise summary of pertinent information. |
1. Partial but accurate summary of pertinent information (>80%). |
1. Poorly organized and/or limited summary of pertinent information (50%-80%); information other than “O” provided. |
1. Does not meet the criteria |
|
Assignment Criteria |
Level III |
Level II |
Level I |
Not Present |
|
Criteria 3 |
Level III Max Points Points: 8 |
Level II Max Points Points: 6.4 |
Level I Max Points Points: 4.8 |
0 Points |
|
Assessment: Problem Identification and Prioritization |
1. Complete problem list generated and rationally prioritized; no extraneous information or issues listed. |
1. Most problems are identified and rationally prioritized, including the “main” problem for the case (>80%). |
1. Some problems are identified (50%-80%); incomplete or inappropriate problem prioritization; includes nonexistent problems or extraneous information included. |
1. Does not meet the criteria |
|
Criteria 4 |
Level III Max Points Points: 8 |
Level II Max Points Points: 6.4 |
Level I Max Points Points: 4.8 |
0 Points |
|
Assessment: Assessment of Current Psychiatric & Medical Condition(s) or Drug Therapy-related Problem |
1. An optimal and thorough assessment is present for each problem |
1. An assessment is present for each problem listed but not optimal |
1. Assessment is present for 50-80% of problems |
1. Does not meet the criteria |
|
Assignment Criteria |
Level III |
Level II |
Level I |
Not Present |
|
Criteria 5 |
Level III Max Points Points: 6 |
Level II Max Points Points: 4.8 |
Level I Max Points Points: 3.6 |
0 Points |
|
Assessment: Treatment Goals |
1. Appropriate and relevant therapeutic goals for each identified problem. |
1. Appropriate therapeutic goals for most identified problems (>80%). |
1. Appropriate therapeutic goals for a few identified problems (50%-80%). |
1. Less than 50% of problems have appropriate therapeutic goals. |
|
Assignment Criteria |
Level III |
Level II |
Level I |
Not Present |
|
Criteria 6 |
Level III Max Points Points: 6 |
Level II Max Points Points: 4.8 |
Level I Max Points Points: 3.6 |
0 Points |
|
Plan: Treatment Plan |
1. Specific, appropriate and justified recommendations (including drug name, strength, route, frequency, and duration of therapy) for each identified problem are included. |
1. Includes most of the requirements for each identified problem (>80%). |
1. Incomplete and/or inappropriate for a few identified problems (50%-80%); information other than “P” provided. |
1. Less than 50% of problems have an appropriate and complete treatment plan. |
|
Criteria 7 |
Level III Max Points Points: 6 |
Level II Max Points Points: 4.8 |
Level I Max Points Points: 3.6 |
0 Points |
|
Plan: Counseling, Referral, Monitoring & Follow-up |
1. Specific patient education points, monitoring parameters, follow-up plan and (where applicable) referral plan for each identified problem. |
1. Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for >80% of identified problems. |
1. Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for a few identified problems (50%-80%). |
1. Less than 50% of problems include appropriate counseling, monitoring, referral and/or follow-up plan. |
|
Maximum Total Points |
50 |
40 |
30 |
|
|
Minimum Total Points |
41 points minimum |
31 points minimum |
1 point minimum |
