SOAP Notes Assessment Examples | Guide & Outline

This short guide provides an analysis of What should be included in a SOAP NOTES Assessment section, and gives three Examples of SOAP notes Assessments sections and SOAP NOTE examples for APRNS.

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What should be included in a SOAP NOTES Assessment sections

The assessment section of a soap note should include 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 AND include the patient’s Informed Consent Ability.

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SOAP NOTE ASSESSMENT OUTLINE

DSM5 Diagnosis: with ICD-10 codes

Dx: –   

Dx: –   

Dx: –   

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.

This was a follow-up appointment from being noncompliant with follow-up appointments and treatment for the last three months. The patient appeared to decline since his last appointment three months ago.

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SOAP NOTE ASSESSMENT EXAMPLE 1

Assessment Diagnosis:

  • (F20.9) Schizophrenia
  • (F10.29) Alcohol use disorder
  • (F14.988) Cocaine use disorder
  • (F12.90) Cannabis use disorder

Differential Diagnosis:

  • (F10.259) Alcohol-induced psychotic disorder
  • (F14.259) Cocaine-induced psychotic disorder
  • (F12.259) Cannabis-induced psychotic disorder

This was a follow-up appointment from being noncompliant with follow-up appointments and treatment for the last three months. The patient appeared to decline since his last appointment three months ago. –

Assessment of Current Psychiatric and Medical Condition(s) or Drug Therapy-related problems:
It appears that the patient is experiencing psychosis related to schizophrenia as seen by the PANSS score of 69. Additionally, AVH is worsened by substance use disorders. He also has alcohol use disorder as evidenced by his AUDIT score of 36. And as cannabis use disorder and cocaine use disorder as evidenced by his DASH-10 score of 8. He was taking Invega Sustenna but was experiencing gynecomastia and was asking for another medication that would help treat schizophrenia without having gynecomastia as a side effect.

Some potential medications to treat schizophrenia are antipsychotics such as Abilify Maintena, Caplyta, and Vraylar. Abilify Maintena would be a great choice for this patient since he is homeless and non-compliant. The patient would not have to worry about carrying around medications, medications getting lost/stolen, or taking them. Would be convenient for him to stay compliant since he will be given the shot every four weeks when he comes in for his follow-up appointments. (This short guide provides an analysis of What should be included in a SOAP NOTES Assessment examples, and gives three Examples of SOAP notes Assessments sections.)

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Caplyta is also a great choice since it is a fast-acting antipsychotic, which will show improvement in his symptoms in one week. However, since this is a pill that has to be taken every day, the patient would have trouble being compliant, which would make the medication ineffective since it has a short half-life. I also think Vraylar is a good choice of medication since it hits the D3 receptors which are known to help those with addiction issues. It also has a long half-life, so if he misses a day, he would not be affected. However, again, this is a pill, so it would be hard for him to stay compliant with taking oral medication. Also, all these medications do not increase prolactin levels significantly which causes gynecomastia, which he is concerned about.

Some potential medications to treat alcohol use disorder are naltrexone and Vivitrol. Since the patient is homeless and noncompliant with taking oral medications daily, I don’t think naltrexone is a good choice. I think Vivitrol is a great choice for this patient since it is a shot to be given monthly, which he can get every four weeks when he comes in for his follow-up appointment.

Currently, there are no medications to help with cocaine use disorder and cannabis use disorder.

I believe that this patient can significantly benefit from attending cognitive behavioral therapy (CBT) to help with schizophrenia, in addition to his multiple substance use disorders. CBT is known to help with schizophrenia and substance use disorders. (This short guide provides an analysis of What should be included in a SOAP NOTES Assessment examples, and gives three Examples of SOAP notes Assessments sections.)

Treatment Goals:

  • (F20.9) Schizophrenia- to reduce/stop auditory and visual hallucinations, so it does not affect patient from performing daily duties (decrease in PANSS score) (This short guide provides an analysis of What should be included in a SOAP NOTES Assessment examples, and gives three Examples of SOAP notes Assessments sections.)
  • (F10.29) Alcohol use disorder- to reduce alcohol consumption to prevent the exacerbation of AVH (decrease in AUDIT score)
  • (F14.988) Cocaine use disorder- to reduce/stop cocaine consumption to prevent the exacerbation of AVH (decrease in DASH-10 score)
  • (F12.90) Cannabis use disorder- to reduce/stop cannabis consumption to prevent the exacerbation of AVH (decrease in DASH-10 score)
  • (F10.259) Alcohol-induced psychotic disorder- to reduce alcohol consumption to prevent the exacerbation of AVH (decrease in PANSS and AUDIT score)
  • (F14.259) Cocaine-induced psychotic disorder- to reduce/stop cocaine consumption to prevent the exacerbation of AVH (decrease in PANSS and DASH-10 score)
  • (F12.259) Cannabis-induced psychotic disorder- to reduce/stop cannabis consumption to prevent the exacerbation of AVH (decrease in PANSS and DASH-10 score)

The patient appears to understand the need for medication and psychotherapy. The patient is willing to adhere to the treatment plan.

Reviewed potential risks & benefits, Black Box warnings, and alternatives, including declining treatment.

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SOAP NOTE ASSESSMENT EXAMPLE 2

Assessment

DSM5 Diagnosis: with ICD-10 codes

Diagnosis

  1. F33.1 Major Depressive Disorder
  2. F41.1 Generalized Anxiety Disorder
  3. F31.9 Bipolar disorder
  4. F40.0 Agoraphobia

Differential Diagnoses:

  1. F33.1 Major Depressive Disorder Recurrent, Moderate (MDD)-confirmed – Bains & Abdijadid (2021) note that individuals who present with sleep disturbances report a significant loss of interest in activities that used to give them pleasure and are currently guilt-ridden for real or imaged causes and feeling worthless are likely candidates for MDD diagnosis. Using the Mnemonic SIG-E-CAPS the MDD diagnosis was confirmed because in addition to sleeplessness, interest loss in earlier pleasurable activities, and guilt- complex, the patient reports a lack of energy manifesting as fatigue. While her cognition is not significantly affected by excessive appetite, psychomotor agitation through anxiety, and being haunted with suicidal thoughts. Most importantly these symptoms have lasted for more than six months increasing in intensity in the last seven weeks. Some potential medications to treat MDD are Selective serotonin reuptake inhibitors: Lexapro, Sertraline, and Fluoxetine. Serotonin-norepinephrine reuptake inhibitors with Cymbalta and Effexor can be another substitute if SSRIs are to be excluded. SSRI classification of medication would be an adequate choice for the patient because of the cost, targeting depression and anxiety, and studied efficacy and acceptability for most patients with minimal side effects. The patient will benefit from Lexapro because she has been successful with the medication on the lower dose, maybe increasing the dose will be the first intervention before switching to other SSRIs. Lexapro regulates a wide range of human behavioral processes, which include mood, perception, memory, anger, aggression, fear, stress response, appetite, addiction, and sexuality (Landy et. al., 2022).
    Considering increasing the dose of Lexapro will be the next step as the patient tolerates the medication with no side effects.
  2. F41.1 Generalized Anxiety Disorder (Confirmed)
    Mental healthcare providers are reminded that GAD and MDD can co-occur and even have some overlapping symptoms like irritability, insomnia, and restlessness. A patient with GAD constantly worries and has difficulties controlling the worry (Stein et al, 2021). It was confirmed as a co-occurring condition t because the patient in context has mood swings, and displays a flat affect with marked appetite changes as evidenced in excessive eating in addition to palpitations and fast breathing amongst other signs and symptoms of GAD.
    Some potential medications to treat GAD are Selective serotonin reuptake inhibitors: Lexapro, Sertraline, and Fluoxetine; Serotonin-norepinephrine reuptake inhibitors with Cymbalta and Effexor can be another substitute if SSRIs are to be excluded as mentioned on MDD. The patient will benefit from Lexapro because she has been successful with the medication on the lower dose, maybe increasing the dose will be the first intervention before switching to other SSRIs. Considering increasing the dose of Lexapro will be the next step as the patient tolerates the medication with no side effects.
  3. F31.10 Bipolar Disorder unspecified –(Refuted)
    CF symptoms as reported are considered unlikely because she admits to not having marked impairment and has never been admitted to the hospital for psychiatric reasons. She denies exhibiting mood swings, mania, or hypomania behavior. Patients with bipolar disorder will most likely experience a full manic episode necessitating admission to a psychiatric institution, unlike bipolar II who experience a less severe hypomanic episode with depression.
  4. F40.0 Agoraphobia – (Refuted)
    This diagnosis does not pertain to CF. The patient reports anxious behavior but did not report around others, especially in crowds at school or feeling trapped.

Treatment goals:

a. (F33.1) Major Depressive Disorder Recurrent, Moderate – Reduction of depressive behaviors, able to enjoy things that she normally enjoys without affecting her daily life (Reduce PHQ 9 score). Increasing the dose of Lexapro will help restore the healthy balance of serotonin in the brain and improve her quality of life.

This short guide provides an analysis of What should be included in a SOAP NOTES Assessment examples, and gives three Examples of SOAP notes Assessments sections.

b. (F41.1) Generalized Anxiety Disorder – Improved coping with anxiety and anxiety symptoms (Reduce GAD 7 score). Increasing the dose of Lexapro will help restore a healthy balance of serotonin in the brain and improve her quality of life.

Informed Consent Ability: The patient has the ability/capacity appears to respond to psychiatric pharmacological and psychotherapy interventions and appears to understand the need for medications/psychotherapy and is ready and willing to adhere to the recommended treatment and care plan.

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SOAP NOTE ASSESSMENT EXAMPLE 3 with Reflections

Assessment:
Mental Status Examination
The patient is a 32-year-old female who looks older than her age. Although the patient is cooperative, she has an abnormally deep voice that is uncharacteristically not common among many women. However, her speech is audible but sometimes disorganized, making it difficult to understand her on some occasions. The patient appears mentally disturbed and exhausted, which could be attributed to current mood disorders due to the emotional and financial burden of caring for two children. Her mood is gloomy, only smiled a few times during the entire interview. The patient experiences visual hallucinations due to her prevailing problems, but there is no evidence of delusional thinking. Also, the patient does not report having any suicidal ideation since she wants a better life for herself and her children and is open to the thought of receiving psychological help to her overcome her current condition. Cognitively, she is not fully attentive, and she has episodes of switching off from the conversation. Her concentration levels are average, but her insight is superb, especially regarding the future.
Differential Diagnoses

1. Mood Disorder

The patient’s constant mood swings emanating from her divorce from her husband indicate that she could be suffering from a mood disorder. Ms. Amy Hartford has trouble adjusting to life after the divorce, and this is causing her to experience a range of emotions such as fighting those close to her, ignoring responsibilities, performing poorly at work, and avoiding family and friends. Also, she easily becomes irritated, and fatigued, and experiences concentration problems, and crying spells. This changing range of emotions indicates the patient is suffering from a mood disorder. According to Truschel (2020), the DSM-5 diagnostic criteria for mood disorder include feeling fatigued, having a depressed mood occasionally, diminished interest in previously pleasurable activities, diminished ability to concentrate or think, reduction of physical movement, and recurrent ideation. In this case, Ms. Amy Hartford meets the criteria for mood disorder because she is constantly depressed, feels fatigued, avoids going out with family and friends, and has a problem concentrating at work. (This short guide provides an analysis of What should be included in a SOAP NOTES Assessment examples, and gives three Examples of SOAP notes Assessments sections.)

2. Schizophrenia

The patient could also have schizophrenia since she reports frequent hallucinations, and she is slightly disordered thinking during the interview. Her positive experiences include auditory and visual hallucinations about the future she wants for her children following the divorce. However, her negative experiences include her flattened voice and facial emotions, withdrawal from friends and family, and struggles fulfilling her responsibilities. According to Newman (2020), the DSM-5 diagnostic criteria for schizophrenia includes hallucinations, concentration problems, confused thoughts, and social withdrawal. The patient meets the diagnostic criteria for schizophrenia because she reports having hallucinations, concentration problems, confused thoughts, and social withdrawal.

3. Anxiety Disorder

The patient could also be experiencing an anxiety disorder because she sometimes reports experiencing sudden feelings of intense anxiety after thinking about how she will raise her two children alone. Due to these anxiety attacks, she has a problem fulfilling her daily responsibilities, such as providing for the children. Her anxiety problems to the divorce from her husband and social withdrawal. The positive attribute is that the anxiety attacks are not frequent, especially now as she transitions to adulthood. According to Cleveland Clinic (2020), anxiety disorder leads to regular nervousness and interferes with an individual’s ability to function. The DSM-5 criteria for anxiety are fatigue, restlessness, and concentration difficulties, which the patient exhibits in the interview. Ms. Army Hartford meets the diagnostic criteria for anxiety disorder because of her concentration problems during the interview and feelings of restlessness when thinking about raising and providing for her two children. This short guide provides an analysis of What should be included in a SOAP NOTES Assessment examples, and gives three Examples of SOAP notes Assessments sections.

Reflections

Several lessons can be drawn from this case study. First, the child welfare system should consider the psychological well-being of parents after divorce. Social workers should ensure that parents are given counseling on how they can move on after divorce and those experiencing problems, particularly psychological issues, should be offered appropriate help, including being referred to a healthcare practitioner for therapy. In this case, the social welfare system did little to follow up on the patient after she got custody of the kids following the divorce, causing her to experience psychological problems in the form of mood and anxiety disorders. Due to her psychological problems, the ethical principle of beneficence should be applied to ensure that the patient’s emotional well-being becomes a priority for her treatment. Health promotion should encompass offering the patient social support so that she can reflect on other things beyond taking care of her children. Due to her mood disorder, social withdrawal from friends and family, and struggles with performing daily responsibilities, the patient should join an emotionally anonymous group. According to Emotional Anonymous International (n.d), emotional anonymous is a 12-step program that supports people with emotional difficulties to enable them to live manageable lives.

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This short guide provides an analysis of What should be included in a SOAP NOTES Assessment section, and gives three Examples of SOAP notes Assessments sections and SOAP NOTE examples for APRNS.
This short guide provides an analysis of What should be included in a SOAP NOTES Assessment examples, and gives three Examples of SOAP notes Assessments sections.

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This short guide provides an analysis of What should be included in a SOAP NOTES Assessment examples, and gives three Examples of SOAP notes Assessments sections.

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