Reference no: EM133786352
Question: Unit 10-Substance Use and Addiction. Clinical soap note on 30 year old Patient addicted to fentanyl.
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 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)
Objective
This is where the "facts" are located.
Vitals,
**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.
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.
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