SOAP Notes For Psychiatry Template

What is a Psychiatry SOAP Notes Template?

Our template is specially designed for psychiatrists to document their clinical notes in an efficient and structured way. Psychiatrists can use Carepatron’s simple-to-use psychiatry SOAP Notes template to ensure their notes meet the internationally recognized SOAP format. SOAP notes are one of the most widespread medical note-taking formats across the world due to their simplicity, reproducibility, and ease of being shared across different providers.

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The SOAP format stands for the four key sections of the SOAP note; Subjective, relating to the recent, subjective experiences of the patient; Objective, which refers to any quantitative clinical data such as medication dosage, height, or weight; Assessment, relating to the clinician’s impression of the patient from this encounter; and Plan, a summary of the next steps in the patient’s treatment plan. For more on SOAP notes in general, check out Carepatron’s introduction to SOAP notes.

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In psychiatry in particular, where a range of complex qualitative and quantitative data must be accurately recorded, SOAP notes provide a great way to clearly and concisely document key findings from a patient encounter. Using the Carepatron SOAP Note template for psychiatry couldn’t be simpler, just follow the four easy steps or check out the explainer video.

How To Use This SOAP Note Template for Psychiatry

This SOAP Note template is great as it serves as a standardized format for note-taking, but also as a guide to the clinical encounter itself. Follow these steps to use our psychiatric SOAP note template.

Download Carepatron’s Psychiatry SOAP Notes Template

Our template has the key sections already set out and ready for you to fill in! Just hit download and you will have your own copy of the PDF psychiatry SOAP Notes template.

Fill in patient and encounter information

At the top of the template, there is space for key information that must be filled in every time the template is used. This includes the patient’s name, date of birth, and optional extra identifier (e.g. MRN, NHS number of NHI). Additionally, the date and time of the patient encounter should be noted here for record-keeping purposes.

Fill in the SOAP sections of the template

Starting with the patient’s subjective experience in the ‘Subjective’ section, continue filling out the four main body sections of the template. The amount of time you spend on each of the SOAP sections depends on your psychiatry practice, and the finished template will naturally be a bit different between practitioners.

Safely store the record

Once the template is completed and all the information you want to note down from this encounter is recorded, it’s time to make sure your SOAP note is safely stored for future use. Psychiatric notes contain sensitive patient information and therefore they must be stored securely and safely. Carepatron provides a HIPAA-compliant way to electronically store your patient notes, ensuring the information is both secure and on hand whenever and wherever you need to access them.

Who Can Use This Psychiatry Template?

This template is designed for anyone who routinely assesses and treats psychiatric patients. While this would typically be a psychiatrist, this template could also be used by healthcare workers, support staff, or allied health professionals who contribute to the patient’s care. They might be:

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• Psychiatrists or psychiatric residents,
• Nurses or nurse practitioners specializing in psychiatric nursing,
• Health workers in prison, community or hospital psychiatric departments,
• Any other healthcare workers in psychiatric settings who routinely assess patients.

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This psychiatric SOAP notes template can be used across the many specialties within psychiatry, such as geriatric, pediatric, forensic, general, or addiction psychiatry. Depending on the specialty of the practitioner, sections of the SOAP notes may be given different priorities, but our psychiatric SOAP Notes template itself is general enough for use across all psychiatric specialties.

Why is This Template Useful For Psychiatrists?

Don’t leave anything out

There’s nothing worse than leaving a patient encounter and realizing you’ve forgotten to ask a crucial question! If you use our psychiatric SOAP notes template, you can be sure you’ve got the key qualitative and quantitative information recorded, as well as your assessment and next steps for the patient, every time.

Spend less time formatting

Using this pre-made template for psychiatric SOAP notes means more time for the important questions you have for your patient, and less time spent formatting notes.

Make sure others can pick up where you left off

Patients are not always seen by the same psychiatrist, and may even transfer between departments throughout their care journey. Starting with a widely used and recognized clinical format, like our psychiatric SOAP Notes template, is a great way to make sure another practitioner can quickly pick up where you have left off if needed.

Benefits of Using the Psychiatry SOAP Note Template

Easily compare changes over time

Only interested in finding out how a patient’s mood has been changing over time? Or do you just want to see what medication schedule they had in the past? Our psychiatric SOAP Notes template separates these different types of information so they can be easily compared over time and clinical decisions can be well-informed by the patient’s treatment history.

Standardize psychiatric note-taking within a practice

In a busy practice, many different staff members might see the same patient and all have important information to contribute to the patient’s clinical record. Making sure these notes are standardized using the same template, like our psychiatric SOAP notes template, means the patient’s EHR is clear, simple to read, and quick to use, even if they have multiple appointments with different practitioners.

Improve communication within your patient’s team

Psychiatrists are one part of a patient’s care team which might include nurses and nurse practitioners, allied health workers, or other medical specialists. As such, it is crucial not only that the psychiatrist’s notes are safely stored and accessible, but also that they are written in a way that is easily understandable by the patient’s whole team. The psychiatric SOAP Notes template produces clearly formatted clinical notes, ensuring any member of your team can quickly find the information they need.

Meet legal requirements

Healthcare practitioners have a responsibility to ensure their clinical records accurately and comprehensively document their interactions with their patients. Should any legal problems arise, it is critical that the psychiatrist can refer to a written record of care, complete with the patient’s information and the date of the encounter. Additionally, insurance companies often require proof of certain treatments or procedures, and having a standard, electronic template for patient notes can benefit practices greatly in these situations.

Access example psychiatric SOAP Notes

Another benefit of using this template is having access to a wealth of example psychiatric SOAP Notes, and easily being able to compare your note-taking to others.