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The Subjective, Objective, Assessment, Plan (SOAP) format of the progress note is widely recognized by clinicians in many specialties, including p
The Plan section should be organized in a way that is systematic and relevant across many psychiatric settings, including outpatient, inpatient, emergency room, jail, pediatric, geriatric, addiction, and consultation-liaison. To best accomplish this, I have designed a format for this section that consists of 6 categories:
1. Safety: Which safety issues need to be addressed?
Examples: If your patient is an inpatient, what precautions are required? If outpatient, Tarasoff? Involuntary hold? Police presence? Child or Adult Protective Services? Access to a firearm?
2. Collateral: Would it be helpful to obtain collateral information from any source?
Examples: Family? Friend? Caregiver? Teacher? Primary care clinician? Therapist? Past medical or psychiatric records?
3. Medical: Are there any medical tests or resources to consider?
Continue to: Examples...
Examples: Laboratory studies or imaging? Consult with a specialist from another field? Nursing orders?
4. Nonpharmacologic: What interventions or assessments would be helpful?
Examples: Psychotherapy? Cognitive testing? Social work? Case manager? Housing assistance? Job coach?
5. Pharmacologic: What interventions or assessments would be helpful? (I placed this category fifth to slow myself down and consider other strategies before quickly jumping to prescribe a medication.)
Examples: Medication? Long-acting injectable? Check pill count? Prescription drug monitoring program?
Continue to: 6. Disposition/follow-up...
6. Disposition/follow-up: What is the disposition/follow-up plan?
Examples: If outpatient, what is the time frame? If inpatient or an emergency room, when should the patient be discharged?
Using these 6 categories in the P section of my SOAP notes has helped me stay organized and think holistically about each patient I assess and treat. I hope other clinicians find this format helpful.
1. Pearce PF, Ferguson LA, George GS, et al. The essential SOAP note in an EHR age. Nurse Pract. 2016;41(2):29-36.
2. Foreman T, Dickstein LJ, Garakani A, et al (eds). A resident’s guide to surviving psychiatric training, 3rd ed. Washington, DC: American Psychiatric Association; 2015.
3. Aftab A, Latorre S, Nagle-Yang S. Effective note-writing: a primer for psychiatry residents. Psychiatric Times. http://www.psychiatrictimes.com/couch-crisis/effective-note-writing-primer-psychiatry-residents. Published January 13, 2017. Accessed August 20, 2018.
The Subjective, Objective, Assessment, Plan (SOAP) format of the progress note is widely recognized by clinicians in many specialties, including p
The Plan section should be organized in a way that is systematic and relevant across many psychiatric settings, including outpatient, inpatient, emergency room, jail, pediatric, geriatric, addiction, and consultation-liaison. To best accomplish this, I have designed a format for this section that consists of 6 categories:
1. Safety: Which safety issues need to be addressed?
Examples: If your patient is an inpatient, what precautions are required? If outpatient, Tarasoff? Involuntary hold? Police presence? Child or Adult Protective Services? Access to a firearm?
2. Collateral: Would it be helpful to obtain collateral information from any source?
Examples: Family? Friend? Caregiver? Teacher? Primary care clinician? Therapist? Past medical or psychiatric records?
3. Medical: Are there any medical tests or resources to consider?
Continue to: Examples...
Examples: Laboratory studies or imaging? Consult with a specialist from another field? Nursing orders?
4. Nonpharmacologic: What interventions or assessments would be helpful?
Examples: Psychotherapy? Cognitive testing? Social work? Case manager? Housing assistance? Job coach?
5. Pharmacologic: What interventions or assessments would be helpful? (I placed this category fifth to slow myself down and consider other strategies before quickly jumping to prescribe a medication.)
Examples: Medication? Long-acting injectable? Check pill count? Prescription drug monitoring program?
Continue to: 6. Disposition/follow-up...
6. Disposition/follow-up: What is the disposition/follow-up plan?
Examples: If outpatient, what is the time frame? If inpatient or an emergency room, when should the patient be discharged?
Using these 6 categories in the P section of my SOAP notes has helped me stay organized and think holistically about each patient I assess and treat. I hope other clinicians find this format helpful.
The Subjective, Objective, Assessment, Plan (SOAP) format of the progress note is widely recognized by clinicians in many specialties, including p
The Plan section should be organized in a way that is systematic and relevant across many psychiatric settings, including outpatient, inpatient, emergency room, jail, pediatric, geriatric, addiction, and consultation-liaison. To best accomplish this, I have designed a format for this section that consists of 6 categories:
1. Safety: Which safety issues need to be addressed?
Examples: If your patient is an inpatient, what precautions are required? If outpatient, Tarasoff? Involuntary hold? Police presence? Child or Adult Protective Services? Access to a firearm?
2. Collateral: Would it be helpful to obtain collateral information from any source?
Examples: Family? Friend? Caregiver? Teacher? Primary care clinician? Therapist? Past medical or psychiatric records?
3. Medical: Are there any medical tests or resources to consider?
Continue to: Examples...
Examples: Laboratory studies or imaging? Consult with a specialist from another field? Nursing orders?
4. Nonpharmacologic: What interventions or assessments would be helpful?
Examples: Psychotherapy? Cognitive testing? Social work? Case manager? Housing assistance? Job coach?
5. Pharmacologic: What interventions or assessments would be helpful? (I placed this category fifth to slow myself down and consider other strategies before quickly jumping to prescribe a medication.)
Examples: Medication? Long-acting injectable? Check pill count? Prescription drug monitoring program?
Continue to: 6. Disposition/follow-up...
6. Disposition/follow-up: What is the disposition/follow-up plan?
Examples: If outpatient, what is the time frame? If inpatient or an emergency room, when should the patient be discharged?
Using these 6 categories in the P section of my SOAP notes has helped me stay organized and think holistically about each patient I assess and treat. I hope other clinicians find this format helpful.
1. Pearce PF, Ferguson LA, George GS, et al. The essential SOAP note in an EHR age. Nurse Pract. 2016;41(2):29-36.
2. Foreman T, Dickstein LJ, Garakani A, et al (eds). A resident’s guide to surviving psychiatric training, 3rd ed. Washington, DC: American Psychiatric Association; 2015.
3. Aftab A, Latorre S, Nagle-Yang S. Effective note-writing: a primer for psychiatry residents. Psychiatric Times. http://www.psychiatrictimes.com/couch-crisis/effective-note-writing-primer-psychiatry-residents. Published January 13, 2017. Accessed August 20, 2018.
1. Pearce PF, Ferguson LA, George GS, et al. The essential SOAP note in an EHR age. Nurse Pract. 2016;41(2):29-36.
2. Foreman T, Dickstein LJ, Garakani A, et al (eds). A resident’s guide to surviving psychiatric training, 3rd ed. Washington, DC: American Psychiatric Association; 2015.
3. Aftab A, Latorre S, Nagle-Yang S. Effective note-writing: a primer for psychiatry residents. Psychiatric Times. http://www.psychiatrictimes.com/couch-crisis/effective-note-writing-primer-psychiatry-residents. Published January 13, 2017. Accessed August 20, 2018.
