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: Susan DOB: not provided Minor: NA Accompanied by: self Demographic: NA Gender Identifier Note: Female CC: “I have been feeling anxious, depresssed, high blood pressure, irregular heartbeat, elevated body temperature, crying spells for the last 2 days” . HPI: Susan is a midde aged woman who reports to the healthcare clinic reporting several symptoms that she has observed over the period of the last two days. She reports having high blood pressure, an irregular heartbeat, depression, anxiety, and an increase in body temperature. Susan doesn't realize that she shows signs of alcohol dependence and physiological dependence, which downplays the seriousness of her alcohol usage. 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 it does to social interactions and job performance. She has also increased her alcohol consumption to ease withdrawal symptoms. s He has a history of drinking, which has caused him to skip work and even get arrested. She downplays her alcohol consumption and justifies how often and how much she drinks. Pertinent history in record and from patient: Alcohol withdrawal During assessment: Patient is cam and corparative Patient seemed to be suffering from serious cases of both anxiety and despair judging from her crying spells. 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 Priorsubstance abuse treatment: not reported Trauma history: Client reveals no history of traumatic experiences (such as abuse, domestic violence, or exposure .

1. 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: Susan
DOB: not provided
Minor: NA
Accompanied by: self
Demographic: NA
Gender Identifier Note: Female
CC: “I have been feeling anxious, depresssed, high blood
pressure, irregular heartbeat, elevated body temperature, crying
spells for the last 2 days”
.
HPI: Susan is a midde aged woman who reports to the
healthcare clinic reporting several symptoms that she has
observed over the period of the last two days. She reports
having high blood pressure, an irregular heartbeat, depression,

2. anxiety, and an increase in body temperature. Susan doesn't
realize that she shows signs of alcohol dependence and
physiological dependence, which downplays the seriousness of
her alcohol usage. 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 it does to social interactions and job
performance. She has also increased her alcohol consumption to
ease withdrawal symptoms. s He has a history of drinking,
which has caused him to skip work and even get arrested. She
downplays her alcohol consumption and justifies how often and
how much she drinks.
Pertinent history in record and from patient: Alcohol
withdrawal
During assessment: Patient is cam and corparative
Patient seemed to be suffering from serious cases of both
anxiety and despair judging from her crying spells.
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,

3. 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
Priorsubstance 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: alcohol use disorder
Family Medical Hx: not repported
Family Psychiatric Hx: not reported

4. Substance use –alcohol abuse
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: increased 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…)
Verify Patient: Name, Assigned identification number (e.g.,
medical record number), Date of birth, Phone number, Social
security number, Address, Photo.

5. Include demographics, chief complaint, subjective information
from the patient, names and relations of others present in the
interview.
HPI:
, Past Medical and Psychiatric History,
Current Medications, Previous Psych Med trials,
Allergies.
Social History, Family History.
Review of Systems (ROS) – if ROS is negative, “ROS
noncontributory,” or “ROS negative with the exception of…”
Objective
Vital Signs: Stable
Temp:98.4
BP:124/78
HR:96
R:20
O2:100%
Pain:
Ht: 5’5”
Wt:120
BMI: 20.0
BMI Range: Heathy weight
LABS:
Lab findings abnomal Hepatic function
Tox screen: positive

6. Alcohol: positive
HCG: N/A
Physical Exam:
MSE:
Patient is fully oriented. Patient is dressed appropriately for age
and season. Psychomotor activity appears within normal.
Presents with coherent speech, expansive, slowed rate.
TC: no abnormal content elicited, denies suicidal ideation and
denieshomicidal ideation. Process appears linear, coherent,
goal-directed.
Cognition appears grossly intact with appropriateattention span
& concentration and average fund of knowledge.
Judgment appears fair . Insight appearsfair
The patient is able to articulate needs, is motivated for
compliance and adherence to medication regimen. Patient is
willing and able to participate with treatment, disposition, and
discharge planning.
This is where the “facts” are located.
Vitals,
**Physical Exam (if performed, will not be performed every
visit in every setting)
Include relevant labs, test results, and Include MSE, risk
assessment here, and psychiatric screening measure results.
Assessment
DSM5 Diagnosis: with ICD-10 codes
Dx: - Alcohol dependence with withdrawal, unspecified ICD-
10-CM Code F10.239
Dx: - Alcohol intoxication ICD-10-CM Code F10.22
Dx: - - Sedative-hypnotic ICD-10-CM Code F13.231

7. 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.
Include your 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.
Informed Consent Ability
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:

8. The patient is put on Zoloft 75mg until she stablizes.
She will be taking 75 milligrams of Zoloft until her condition
stabilizes. Depression and anxiety are common among those
who abuse alcohol, and zoloft may help alleviate these
symptoms. Likewise, cognitive behavioral therapy (CBT) is the
psychotherapist of choice for treating alcohol dependence
(Gibney, 2018). Here, the patient and therapist will discuss
potential strategies for mitigating the impact of the symptoms.
Providing for the psychological, social, and physical needs of
students in their educational programs. Medication is key, but
psychoeducational counseling for the affected individual and
their family members is also highly recommended (Johansson,
et al., 2021).
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 18 minutes
Visit lasted 55 minutes
Billing Codes for visit:
XX
XX
XX
____________________________________________
NAME, TITLE

9. Date: Click here to enter a date.Time: X
References
Gibney, S. (2018). An Unfinished Story, an Unfinished Body:
How Missing Health Histories Predispose Adoptees to Illness.
Narrative Inquiry in Bioethics,

10. 8(2), 109-111.
Project MUSE - An Unfinished Story, an Unfinished
Body: How Missing Health Histories Predispose Adoptees to
Illness (jhu.edu)
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.
Journal of Medical Internet Research - 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 (jmir.org)