7.1 Intro to PMHNP SOAP Note

7.1 Intro to PMHNP SOAP Note

PMHNP SOAP Note questionnaire

Consulting the Answer Key, please answer the following questions:

1.      What does the S stand for in the SOAP note format?

2.      What information is contained in the S section?

3.      What does the O stand for in the SOAP note format?

4.      What information is contained in the O section?

5.      What does the A stand for in the SOAP note format?

6.      What information is contained in the A section?

7.      What does the P stand for in the SOAP note format?

8.      What information is contained in the P section?

9.      What is the purpose of the PMHNP Soap Note?

10.  Which section contains information that can be observed or measured?

11.  Which section contains the differential diagnoses?

12.  Which section contains the Mental Status Exam (MSE)?

Answer key:

These terms may be applicable to more than one question.

·       Subjective

·       Guides clinical reasoning, diagnosis, and treatment decisions; facilitates communication among providers, tracks progress

·       Objective

·       Chief complaint, demographic information, HPI, PMH, Social History

·       Plan

·       Assessment

·       VS, ROS, MSE, labs, screening assessments, “facts”

·       Diagnosis and differential diagnoses, DSM-5 criteria, and potential treatment options

·       Specific instructions for medications and dosing, lab work ordered, referrals, therapy recommendations, follow up