The PLAN section of a SOAP note plays an integral role in showing the clinical reasoning and decision-making skills of a PMHNP or APRN. This short guide includes 3 SOAP note plan examples you can use when writing. Alternatively, since most have to do these SOAP notes every other week, let our nursing writers do it for you this week as you do other important things.(SOAP NOTE Plan Examples)
SOAP NOTE Plan Outline
- Pharmacological plan
- non-pharmacological plan
- Educational Plan
- Referrals – Consultation/Collaboration plan
- Follow-up plan
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SOAP NOTE Plan Examples 1
|Therapeutics: Stop Invega Sustenna IM every 4 weeks due to gynecomastia. Start Abilify Maintena 800mg IM one time today and Abilify 20mg PO one time today, then Abilify Maintena 400mg IM every 4 weeks for schizophrenia. My preceptor chose to initiate Abilify Maintena 800mg IM with Abilify 20mg PO on day 1, then Abilify 400mg IM every 4 weeks versus Abilify Maintena 400mg IM on day 1 with Abilify 20mg for 14 days because the patient stated that he would not be compliant with taking oral medication. The patient is also known to tolerate Abilify well in the past. Start Vivitrol 380mg IM every 4 weeks for alcohol use disorder. Order fasting lipids, HbgA1C, CBC with diff, and fasting plasma glucose to get a baseline since atypical antipsychotics can cause multiple metabolic side effects and leukopenia/neutropenia. Order liver panel since Vivitrol is metabolized in the liver and since the patient has a history of drinking daily.
Educational: Educate the patient on the importance of being compliant with medication and psychotherapy. Educate the patient on the common and dangerous side effects of Abilify Maintena and Vivitrol. Some side effects of Abilify Maintena include dizziness, insomnia, akathisia, nausea, and vomiting. Some side effects of Vivitrol include nausea, vomiting, dizziness, insomnia, and headache. Educate the importance of sleep hygiene, meditation, and yoga for overall mental health. Educate the importance of physical activity to help prevent the metabolic side effects of an atypical antipsychotic. Educate the patient on the importance of psychotherapy, specifically cognitive-behavioral therapy, to help with schizophrenia and substance use disorders. The patient was educated on the negative effects of alcohol, cannabis, and cocaine. The benefits of joining a substance abuse rehabilitation program were discussed. Also discussed patient to see primary care provider get a full body health assessment and labs.
Consultation/Collaboration: Continue psychotherapy with the psychologist or licensed counselor every week—cognitive behavioral therapy for schizophrenia and multiple substance use disorders. Consult with a social worker to help patient find housing and clothes. Consult substance abuse rehabilitation program for multiple substance use disorders. Consult primary care provider to perform annual preventative health assessment and labs.
Follow up: Follow up in two weeks- will initially follow up every two weeks for the first two months, then every four weeks to see the patient’s progress. Will continue to monitor PANSS, AUDIT, and DASH-10 scores. Will also monitor labs every six months and report any abnormal labs to the primary care provider.
|The PLAN section of a SOAP note plays an integral role in showing the clinical reasoning and decision-making skills of a PMHNP or APRN. This short guide includes 3 SOAP note plan examples you can use when writing.
SOAP NOTE Plan Examples 2
- 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 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 the chart, at this time
- or…Zoloft is an excellent option for many women who experience any menstrual cycle complaints. I usually start at 50 mg and move to 100 weeks 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(SOAP NOTE Plan Examples)
- Discussed current tobacco use. NRT not indicated.
- Safety planning
- Discuss worsening sx and when to contact the office or report to ED
Referrals: an endocrinologist for diabetes
Follow-up, including the return to the clinic (RTC) with time frame and reason and any labs that are needed for the next visit 2 weeks
SOAP NOTE Plan Examples 3
|Pharmacological Interventions The escitalopram dosage should be increased to 20mg /day to determine the medication’s maximum effectiveness. (Jiang et al, 2016). According to this researcher, the efficacy of Lexapro medication in treating MDD comorbid with a generalized anxiety disorder has been determined in short-term studies. The drug works by increasing intrasynaptic levels of neurotransmitters serotonin. It does this action by blocking the reuptake of the neurotransmitter into the presynaptic neuron. Will obtain CBC with diff, fasting lipids, and HbgA1C.
Nonpharmacological interventions Education First education to CJ was to be aware of the importance of adhering to her medication and CBT times. The patient should be made aware of Escitalopram 20mg side effects of headache, nausea, dry mouth, and constipation. Other side effects associated are weight gain, flatulence, menstrual disorder, and decreased libido. (SOAP NOTE Plan Examples)
CJ was educated to avoid any use of alcohol, nicotine, or drugs, including medications not prescribed for her.
The patient was informed to communicate with other people and talk with people she trusts about how she’s feeling.
Attend all your psychiatrist and therapists’ appointments.
Educate the patient on relaxation techniques to lower stress.
Educate CJ to do things that she enjoys such as (gardening, walking in nature, and going to a movie).
Always Reward self for every success.
Referral The patient is to be referred to a Psychotherapist for CBT. The patient will be referred to the Primary care Physician for follow-up regarding the mild BP elevation.
Follow-up Return for follow-up in 4-6 weeks, or earlier if the symptoms get worse despite the increased dosage of Lexapro to 20mg.(SOAP NOTE Plan Examples)