Initial Psychiatric Interview/SOAP Note Template
Criteria
Clinical Notes
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)
Subjective
Verify Patient
Name: MH
DOB: not provided
Minor: NA
Accompanied by: self
Demographic: NA
Gender Identifier Note: Male
CC: “I don’t drink when I am working and do not remember ”
.
HPI: the patient reports to the healthcare clinic reporting several symptoms. The patient’s CIWA is 10. The patient however states that she does not drink while at work. This diagnosis is supported by the withdrawal symptoms that appear to be becoming more tolerable as well as by the sustained and increased alcohol consumption despite the harm.
Pertinent history in record and from patient: alcohol abuse
During assessment: Patient is calm and corparative.
Patient denies hallucinating. The patient has nomal thought process. .
SI/ HI/ AV: patient denies signs of suicidal ideation and violent behavior.
Allergies: NKDFA.
(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: NKDA
Describes stable course of illness.
Previous medication trials: not reported
Safety concerns:
History of Violence to Self:none reported
History of Violence t o Others: none reported
Auditory Hallucinations: not 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 reveals no history of traumatic experiences (such as abuse, domestic violence, or exposure to upsetting events).
Substance Use: the patient reports alcohol abuse
Client does report abuse of or dependence on alcohol.
Current Medications: NKDA
(Contraceptives):
Supplements:
Past Psych Med Trials: acohol abuse
Family Medical Hx: not reported
Family Psychiatric Hx: not reported
Substance use –NKDA
Suicides-not reported
Psychiatric diagnoses/hospitalization-not reported
Developmental diagnoses
Social History:
Occupational History: currently unemployed.
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.
ROS:
Constitutional: no fever reported.
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: reports 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…)
Objective
Assessment
DSM5 Diagnosis: with ICD-10 codes
Dx: – Alcohol withdrawal ICD-10 CM-F10.230
Dx: Alcohol dependence with withdrawal, unspecified ICD-10-CM Code F10.239
Dx: Alcohol intoxication ICD-10-CM Code F10.22
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.
Plan
(Note some items may only be applicable in the inpatient environment)
Inpatient:
Psychiatric. NKDA
Estimated stay
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:
The patient is put on Diazepam 5gm daily until she stablizes.
Alcoholism with simple withdrawal symptoms Alcohol dependence with withdrawal, simple, is a legitimate billable ICD-10 diagnostic code. It can be utilized in any HIPAA-covered transactions and can be found in the 2022 edition of the ICD-10 Clinical Modification (CM). A score for each CIWA protocol item ranges from 0 to 7, with higher values indicating more severe symptoms (Gibney, 2018). The last test question concerns orientation to time and location and is graded from 0-4. The patient’s self-reported symptoms and palpable symptoms are used to calculate the CIWA score (Johansson, et al 2021).
The patient is educated on the coping skills and hoiw to take the medication as instructed.
Follow-up, including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit 4 weeks
☒>50% time spent counseling/coordination of care.
Time spent in Psychotherapy 15 minutes
Visit lasted 55 minutes
____Ramona Wilkerson PHMNP student ________________________________________
NAME, TITLE
Date: 11/10/2022Time: 11:30am
References
Gibney, S. (2018). An Unfinished Story, an Unfinished Body: How Missing Health Histories Predispose Adoptees to Illness. Narrative Inquiry in Bioethics, 8(2), 109-111.
Johansson, M., Berman, A. H., Sinadinovic, K., Lindner, P., Hermansson, U., & Andréasson, S. (2021). Effects of internet-based cognitive behavioral therapy for harmful alcohol use and alcohol dependence as self-help or with therapist guidance: three-armed randomized trial. Journal of medical Internet research, 23(11), e29666.
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