This sample SO AP note was created using the ICANotes ...
This sample SOAP note was created using the ICANotes Behavioral Health EHR. The only words typed by the clinician are highlighted in yellow. Visit for a free trial or demo.
October Boyles, LPC 123 Main Street, Suite 202
Anywhere, US 12345 Tel: 555-678-9100 Fax: 555-678-9111
Chapman, Piper
1/30/2019 9:50:04 AM
SUBJECTIVE:
ID: 1000010665675
DOB: 1/1/1989
SOAP Note / Counseling
Piper states, "I feel better today. I think my depression is improving. The therapy is helping."
OBJECTIVE: Compliance with medication is good. Her self-care skills are intact. Her relationships with family and friends are reduced. Her work performance is marginal. She has maintained sobriety. Ms. Chapman has normal food and fluid intake. Weight is stable and unchanged. Sleep problems are reported. Difficulty falling asleep is reported. Difficulty staying asleep is reported.
ASSESSMENT: Ms. Chapman presents as calm, attentive, and relaxed. She exhibits speech that is normal in rate, volume, and articulation and is coherent and spontaneous. Language skills are intact. Body posture and attitude convey an underlying depressed mood. Facial expression and general demeanor reveal depressed mood. Affect is appropriate, full range, and congruent with mood. There are no apparent signs of hallucinations, delusions, bizarre behaviors, or other indicators of psychotic process. Associations are intact, thinking is logical, and thought content appears appropriate. Suicidal ideas are convincingly denied. Homicidal ideas or intentions are denied. Cognitive functioning and fund of knowledge are intact and age appropriate. Short- and long-term memory are intact, as is ability to abstract and do arithmetic calculations. This patient is fully oriented. Insight into problems appears normal. Judgment appears fair. There are no signs of anxiety. Ms. Chapman's behavior in the session was cooperative and attentive with no gross behavioral abnormalities. No signs of withdrawal or intoxication are in evidence.
PLAN:
DIAGNOSES: The following diagnoses are based on currently available information and may change as additional information becomes available. Anxiety disorder, unspecified, F41.9 (ICD-10) (Active) Dysthymic disorder, F34.1 (ICD-10) (Inactive) Borderline personality disorder, F60.3 (ICD-10) (Active) Major depressive disorder, recurrent, moderate, F33.1 (ICD-10) (Active) Binge eating disorder, F50.81 (ICD-10) (Active) Hoarding disorder, F42.3 (ICD-10) (Active) Panic disorder [episodic paroxysmal anxiety], F41.0 (ICD-10) (Active) Generalized anxiety disorder, F41.1 (ICD-10) (Active)
Link to Treatment Plan Problem: Depressed Mood
PROBLEM: Depressed Mood Ms. Chapman's depressed mood has been identified as an active problem requiring treatment. It is primarily evidenced by: Diagnosis of Depression:
*Without History of Treatment
LONG-TERM GOAL: Ms. Chapman will develop the ability to recognize, accept and cope with feelings of depression.
SHORT-TERM GOAL(S) & INTERVENTIONS: Short-Term Goal / Objective:
Ms. Chapman will replace negative and self-defeating self talk with verbalization of realistic and positive cognitive messages. Target Date: 3/1/19 Status: Effective
Intervention: Therapist/Counselor will provide emotional support and encouragement, to help Ms. Chapman to focus on sources of pleasure and meaning. Progress will be monitored and documented. ----------------------
Good progress in reaching these goals and resolving problems seemed apparent today.
Recommend continuing the current intervention and short-term goals as they exist, since progress is being made but goals have not yet been met.
Notes & Risk Factors: History of substance abuse History of cutting History of medication non-compliance Diabetes Has been assaultive
90837 Psychotherapy 60 min.
Time spent face to face with patient and/or family and coordination of care: 60 min
October Boyles, LPC
Electronically Signed By: October Boyles, LPC On: 1/30/2019 9:58:44 AM
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- effectiveness of an integrative approach on adjustment
- coding and documentation recommendations for outlining
- adnm 20 questionnaire adjustment disorder new module 20
- this sample so ap note was created using the icanotes
- dsm 5 update
- pamphlet 155 2 appendix 8 icd10 and icd9
- 2013 icd 9 cm diagnosis code 309 0 adjustment disorder
- behavioral health icd 10 documentation tips
- the icd 10 classification of mental and behavioural
- ii illinois department of human services
Related searches
- the internet was created when
- microsoft was created when
- sample thank you note for teachers
- who was apart of the scientific revolution
- who was involved in the scientific revolution
- what was invented during the scientific revolution
- what was developed during the neolithic era
- graph this line using the slope calculator
- what was popular in the 70s
- earth was created when
- 2020 exam sample questions ap chemistry
- when was created netflix