Need a total of 25 mini soap notes. Patients should be ages 18 and younger.
Example provided:
17 y/o African American, female
“Follow up on my mood”
S: Patient is being seen for a follow up visit. Patient has a history of depression, bipolar, gender identity crisis and cannabis use. Patient recently changed her name stating her birth name wasn't “identifiable”. Patient has complaints of feeling mentally drained and overworked. She states she's tired and is considering going to an inpatient mental health facility for a few days. Patient who lives at home with her parents has decided that it would be best if she went to live with her grandmother. She states her parents does not understand her identity. She has resorted to excessive alcohol and marijuana use to “ease the pain”. Patient has exhibited symptoms of impulsive behaviors by going on shopping sprees, only using her credit cards. Patient is currently taking Abilify 20mg PO daily, Sertraline 50mg PO daily and Concerta 27mg PO daily. NKDA
O: Temp 97.9, BP 1/22/80, HR 70, O2 sats 99%
A: Bipolar disorder- Bipolar I Disorder – F31.13
Substance Use Disorder (Alcohol and Marijuana) – F10.20, F12.10
P: Increase Abilify to 30mg PO daily. Continue all other psychiatric medications as prescribed and monitored for changes in behavior and/or adverse reactions. Education provided to patient. Reviewed medication side effects and adherence importance. Keep tracks of physical symptoms of mood and depression and triggers associated. Discussed worsening signs and symptoms and when to contact office or report to ED. Patient advised to continue with outpatient counseling. Referred to substance abuse treatment program. Follow up in four weeks or sooner if symptoms worsen.
