Subjective Section of the SOAP Psychiatric progress note?

[prominence]

Generally speaking, what are some types of topics psychiatrists should be asking/writing about in the subjective section of the SOAP psychiatric progress note?

I struggle with this when I am asked to substitute on the inpatient psychiatric unit and don't know the patients well and the patients aren't forthcoming to speak with me. As a result, they are mostly replying to questions I am asking about rather than speaking to me freely.

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[zenman]

Generally speaking, what are some types of topics psychiatrists should be asking/writing about in the subjective section of the SOAP psychiatric progress note?

I struggle with this when I am asked to substitute on the inpatient psychiatric unit and don't know the patients well and the patients aren't forthcoming to speak with me. As a result, they are mostly replying to questions I am asking about rather than speaking to me freely.

I usually just ask something like, "What's going on with you?" "What can I help you with? "How can I help you?"...anything to get them going. Some places are a little different but I usually put in a quote from a patient and then might place the rest of appropriate subjective info in my own words such as "client reports that he has a monkey on his back."

 

[OldPsychDoc]

Generally speaking, what are some types of topics psychiatrists should be asking/writing about in the subjective section of the SOAP psychiatric progress note?

I struggle with this when I am asked to substitute on the inpatient psychiatric unit and don't know the patients well and the patients aren't forthcoming to speak with me. As a result, they are mostly replying to questions I am asking about rather than speaking to me freely.

Why struggle? You're not getting graded anymore!
If they don't say much, then document that.
Document interim changes in mood, sleep, appetite, psychosis, SI/HI, side effects and physical conditions, and boom--you're done. Any crazy quotes are just gravy.

 

[nitemagi]

Why struggle? You're not getting graded anymore!
If they don't say much, then document that.
Document interim changes in mood, sleep, appetite, psychosis, SI/HI, side effects and physical conditions, and boom--you're done. Any crazy quotes are just gravy.

I agree, follow the target symptoms, whatever they may be. And I would add medicolegal issues - such as if they came in suicidal, document that they've had no impulsive behaviors or self-harming behaviors in last day.