Initial Psychiatric Interview/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.
Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion)
Gender Identifier Note:
Pertinent history in record and from patient: X
During assessment: Patient describes their mood as X and indicated it has gotten worse in TIME.
Patient self-esteem appears fair, no reported feelings of excessive guilt,
no reported anhedonia, does not report sleep disturbance, does not report change in appetite, does not report libido disturbances, does not report change in energy,
no reported changes in concentration or memory.
Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. Patient does not report excessive fears, worries or panic attacks.
Patient does not report hallucinations, delusions, obsessions or compulsions. Patients activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a characterological nature.
SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors.
(medication & food)
Past Medical Hx:
Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury.
Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C.
Surgical history no surgical history reported
Past Psychiatric Hx:
Previous psychiatric diagnoses: none reported.
Describes stable course of illness.
Previous medication trials: none reported.
History of Violence
to Self: none reported
History of Violence t
o Others: none reported
Mental health treatment history discussed:
History of outpatient treatment: not reported
Previous psychiatric hospitalizations: not reported
Prior substance abuse treatment: not reported
Trauma history: Client does not report history of trauma including abuse, domestic violence, witnessing disturbing events.
Substance Use: Client denies use or dependence on nicotine/tobacco products.
Client does not report abuse of or dependence on ETOH, and other illicit drugs.
Current Medications: No current medications.
Past Psych Med Trials:
Family Medical Hx:
Family Psychiatric Hx:
Occupational History: currently unemployed. Denies previous occupational hx
Military service History: Denies previous military hx.
Education history: completed HS and vocational certificate
Developmental History: no significant details reported.
(Childhood History include in utero if available)
Legal History: no reported/known legal issues, no reported/known conservator or guardian.
Spiritual/Cultural Considerations: none reported.
Constitutional: No report of fever or weight loss.
Eyes: No report of acute vision changes or eye pain.
ENT: No report of hearing changes or difficulty swallowing.
Cardiac: No report of chest pain, edema or orthopnea.
Respiratory: Denies dyspnea, cough or wheeze.
GI: No report of abdominal pain.
GU: No report of dysuria or hematuria.
Musculoskeletal: No report of joint pain or swelling.
Skin: No report of rash, lesion, abrasions.
Neurologic: No report of seizures, blackout, numbness or focal weakness. Endocrine: No report of polyuria or polydipsia.
Hematologic: No report of blood clots or easy bleeding.
Allergy: No report of hives or allergic reaction.
Reproductive: No report of significant issues. (females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc)
Verify Patient: Name, Assigned
identificationnumber (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo.
Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview.
, Past Medical and Psychiatric History,
Current Medications, Previous Psych Med trials,
Social History, Family History.
Review of Systems (ROS) if ROS is negative, ROS noncontributory, or ROS negative with the exception of
Vital Signs: Stable
Lab findings WNL
Tox screen: Negative
Patient is cooperative and conversant, appears without acute distress, and fully oriented x 4. Patient is dressed appropriately for age and season. Psychomotor activity appears within normal.
Presents with appropriate eye contact, euthymic affect – full, even, congruent with reported mood of x. Speech: spontaneous, normal rate, appropriate volume/tone with no problems expressing self.
TC: no abnormal content elicited, denies suicidal ideation and denies homicidal ideation. Process appears linear, coherent, goal-directed.
Cognition appears grossly intact with appropriate attention span & concentration and average fund of knowledge.
Judgment appears fair . Insight appears fair
The patient is able to articulate needs, is motivated for compliance and adherence to medication regimen. Patient is willing and able to participate with treatment, disposition, and discharge planning.
This is where the facts are located.
**Physical Exam (if performed, will not be performed every visit in every setting)
Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results.
DSM5 Diagnosis: with ICD-10 codes
Patient has the ability/capacity appears to respond to psychiatric medications/psychotherapy and appears to understand the need for medications/psychotherapy and is willing to maintain adherent.
Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment.
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.
Informed Consent Ability
(Note some items may only be applicable in the inpatient environment)
Psychiatric. Admits to X as per HPI.
Estimated stay 3-5 days
Safety Risk/Plan: Patient is found to be stable and has control of behavior. Patient likely poses a minimal risk to self and a minimal risk to others at this time.
Patient denies abnormal perceptions and does not appear to be responding to internal stimuli.
Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic:
No changes to current medication, as listed in chart, at this time
orZoloft is an excellent option for many women who experience any menstrual cycle complaints. I usually start at 50 mg and move to 100 week 6-8. f/u within 2 weeks initially then every 6-8 weeks.
Psychotherapy referral for CBT
Education, including health promotion, maintenance, and psychosocial needs
Importance of medication
Discussed current tobacco use. NRT not indicated.
Discuss worsening sx and when to contact office or report to ED
Referrals: endocrinologist for diabetes
Follow-up, including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit 2 weeks
> 50% time spent counseling/coordination of care.
Time spent in Psychotherapy 18 minutes
Visit lasted 55 minutes
Billing Codes for visit:
Date: Click here to enter a date. Time: X This week in clinical I assessed a client with a history of Bipolar who was displaying symptoms of severe anxiety and depression. She was experiencing delusions and signs of early dementia as well. Consult was written for catscan which was negative. Patient was stating her husband was poisoning her and that she is going to get fired from her job for breaching security Once collaboration was made with the social worker, employer, and family we were able to conclude that she was extremely delusional. Patient was on Effexor and this medication doesnt do well for someone with her symptoms so we begin a taper down from 112.5 she was placed on Abilify 10 mg we will begin tapering down on Effexor and up on Abilify until she stabilizes. Patient is being referred for ECT.
4 Page Story
126 R E T H I N K I N G S E X I S M , G E N D E R , A N D S E X U A L I T Y
Creating a classroom book
that reflects the class
By Willow McCormick
Willow McCormick is a 2nd-grade teacher in West Linn, Oregon. She is an Oregon
Writing Project consultant and a Library of Congress Civil Rights Institute fellow.
have more than 1,000 books in my classroom library, cobbled together
from garage sales, used bookstores, and the collections of former students
who have outgrown their picture books. As a social justice educator, I try
to fill my primary classroom library with books that feature characters
from a variety of cultures, traditions, classes, and backgrounds. And yet, despite
my efforts, Im dismayed by how many of the thoughtful, well-written books in
my collection feature the nuclear family unit, be it human or animal. Even my
favorite authors default to the nuke.
Kevin Henkes is a perennial favorite in primary classrooms across the
country. The mice that populate his books cope with universal struggles of
young childrenseparation anxiety, teasing, loneliness, empathy. Unfortunately,
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C H A P T E R 3 : O U R C U R R I C U L U M 127
Henkes books present something else as universal as well: a doting mother and
father plus a sibling or two waiting at home to soothe and support the struggler.
Trudy Ludwig has written an excellent collection of books, including Trouble
Talk and Sorry!, that dig into the power dynamics among children and offer
strategies on how a child can transition from being a target to a self-advocate
with a little help from mom, dad, and brother in a tidy, suburban home. The
message of empowerment is a noble and essential one, which is why I read these
books to my class every year. But another message is being conveyed as well
when these books are read back to back: two-parent heterosexual families are
When a book does acknowledge the existence of other family structures, the
difference is often the focus of the storyhow Addison has two fancy houses
instead of one in Tamara Schmitzs Standing on My Own Two Feet: A Childs
Affirmation of Love in the Midst of Divorce. If you want to read a story featur-
ing children in foster care, youll have to look long and hard for anything other
than guides for making the transition in or out of care. It takes a lot of work to
find books that include same-gender parents, step-parents, foster or adopted
children, or other nontraditional families as background in an adventure tale, a
friendship parable, or a holiday romp.
When two-parent, heterosexual families are presented as the norm in story
after story, year in and year out, an insidious message is conveyed: Families that
dont conform to this structure are not normal. And, of course, the message is
reinforced in the majority of movies and television shows geared toward chil-
dren. Shame, secrecy, and evasion can result from this incessant messaging.
I see it play out in my classroom. Two years ago, I had a student with di-
vorced lesbian moms, step-siblings, half-siblings, and a close-knit extended fam-
ily. I doubt any childrens book out there includes a family like hers. They were
a loud and loving family, and Marie was a loud and loving girl. Yet she rarely
divulged that she had two moms and, in fact, fabricated an absentee dad at one
point early in the year. Another boy, Andrew, didnt want anyone to know he was
adopted, afraid they would think he was weird. He said it was hard enough
having brown skin when his parents and most of his classmates were white; he
didnt want kids to think of him as different in another way, too. I pride myself
on having an accepting and appreciative classroom community, but the under-
mining effect of the dominant family system in childrens books and media slips
into our snug community like toxic smoke.
What is a 2nd-grade teacher to do? Dispose of all Kevin Henkes books, and
deprive 7-year-olds of the pleasure of repeating Chrysanthemum, Chrysan-
themum, Chrysanthemum as they root for the main character to embrace her
unusual name and accept herself? Give periodic rambling qualifiers before read-
alouds, trying to explain the heteronormative paradigm in kid-friendly lan-
guage? Build a library where every family structure is represented equally, thus
ensuring a library of 100 books or fewer? Ive considered all of these scenarios in
moments of exasperation, but nothing seems realistic.
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128 R E T H I N K I N G S E X I S M , G E N D E R , A N D S E X U A L I T Y
Susan Kuklins Families
Luckily there are resources out there that shine a light on a path forward. A
few years ago I discovered a beautiful book by Susan Kuklin simply titled Fam-
ilies. Kuklin puts family structure in a larger context of diversity of all types. To
create the book, she interviewed children aged 4 to 14 from a variety of family
structures, mainly in New York City, but also in rural communities. She then
worked with the children to select a pages worth of text describing their family
members, religious traditions, household, hobbies, and studies. A family portrait
accompanies each page; the children themselves chose the location, clothing
worn by all family members, pets, and props. The net effect is a refreshingly
matter-of-fact look at 16 very different families. Ella is a summer camp aficiona-
do who was adopted by her two fathers as a baby. Theres also Kira and Matias,
biracial children who live beside a creek and love catching fish for dinner. Yaa-
kov, Leah, Miriam, and Asher are Orthodox Jews who make themselves laugh
with goofy invented languages. Chris, Louie, and Adam are close-knit broth-
ers whose parents come from Puerto Rico and the Dominican Republic; they
discuss food and language, only mentioning in passing that Louie has Down
We Make Our Own Book
Families has all sorts of potential for classroom use. I use it as a mentor text
for writing our own class book of families. Each day I read aloud one family
story to the class. The straightforward tone of the book leads easily to a straight-
forward discussion afterward. I ask the kids to make connections between the
family we just met in the book and their own families, or the families of their
friends or neighbors. What do they have in common? What are some differenc-
es? The class often starts with the goofy languagesthey make up silly words,
too!or the hobbies or study habits they share with the children in the book.
But its not long before the conversation gets more personal. Finn mentions
his gay aunts, two children of divorced families compare how they split upor
donttheir time between households, devout Christian Isaiah notices that he
and a Muslim boy in the book both consider themselves servants of God.
Over time, we begin to craft our own narratives. First we brainstorm themes
that come up again and again in the bookfood, religion, traditions, sports and
hobbies, descriptions of family membersand the kids start to make lists from
their own lives that fit into these categories. Then they write, each in their own
style. Ramona tells how her cousins came to live with her family as foster chil-
dren. My mom wanted to know how long they would be staying, but now were
all glad they came. Isaiah tells us that religion is the biggest part of his familys
life. Marie writes about her two moms, and Rory explains that he doesnt have
a dad or siblings, but his uncles and pets fill in, and he and his mom have an
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C H A P T E R 3 : O U R C U R R I C U L U M 129
extra special relationship because its just the two of them. Andrew, after a few
fretful conferences with a couple of trusted peers and me, decides to include his
adoption in his narrative:
Hi, I am Andrew. I am 8 years old. I have one sister and no brothers.
I live in Oregon. I was adopted because my birth mom could not
take care of me. My dad was at work when the phone rang. Some-
body said into the phone, Jon, do you want to be a dad? Yes!
After one day my mom and my dad came to the place where I was.
My new mom and dad took me home.
The undermining effect of the
dominant family system in childrens
books and media slips into our snug
community like toxic smoke.
Once the narratives are crafted, the kids bring in photos to use as illustra-
tions, or direct me to photograph them doing things they love at school. They
paste their narratives and photos on oversized construction paper to create their
own page in our classroom edition of Families.
To draw the project to a close, I host a writing celebration in the classroom.
The children lay their pages out carefully on the tables and we spend the hour
rotating from desk to desk, reading stories and leaving notes of praise and con-
nection. My family goes hiking on Easter, too! You have two moms?! You are
At the end of the day, I collect all the pages and bind them together. Now
theres at least one book in our classroom library where all of my students can
find themselves. When I think about how intently the majority of my students
read and respond to the writing of their peers, I realize that, even if my class-
room were fully stocked with high-quality literature featuring a complete spec-
trum of family structures, Id still want this book, our book, at the center of my
library. It is satisfying for the students to see themselves reflected in the books
and other media that surround them. But it is also powerfuland comforting
for children to see and be seen by their own peers. Ultimately I want both for my
students: a world in which they feel they belong, and a classroom community in
which they feel known.
EBSCOhost – printed on 5/26/2021 8:54 AM via NEW JERSEY CITY UNIV. All use subject to https://www.ebsco.com/terms-of-use Each journal entry must be between 250-300 words. The journal entries will
provide an opportunity for students to share their analysis and reflection of the
assigned readings for that weeks session. The journal entries will also serve to
enable students to discuss the research materials they are utilizing for their
signature assignment with their classroom peers.
In each journal post:
Discuss the main points raised by the authors of the assigned readings.
What perspectives are the authors putting forward? What are the authors
seeking to emphasize or focus on?
How do the readings inform your thinking about LGBTQ issues in schools
and in education in general?
What do you believe is the most important point or conclusion that the
authors are providing? Why do you believe this point/conclusion to be