Psych book question

[human being]

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What book will help me improve my documentation and soap note in my psych clerkship?

 

[evilbooyaa]

Honestly, each attending I've seen during my psych rotation has his/her own template that they prefer to use for a SOAP note. I would ask whatever attending or resident you are working with what the expectation is.

General stuff to include (at least based on my template) - Patient's mood, sleep, appetite, suicidal/homicidal ideation, hallucinations, issues with meds (more important if recently switched)

At least this is what I did for in-patient.

 

[zenman]

What book will help me improve my documentation and soap note in my psych clerkship?

You can revise mine. It's geared to the military. I just use Dragon and dictate plus change whatever I need in MSE.

Psychiatry Progress Note

Time start:
Time end:

SUBJECTIVE:



CURRENT MEDICATIONS:

Meds reviewed and reconciled.

OBJECTIVE: (Mental Status Exam): The patient was evaluated in behavioral health clinic with appropriate duty uniform, hygiene, and appeared his stated age. Psychomotor activity was normal. Height and weight was appropriate. Patient was pleasant, cooperative, and had appropriate eye contact. Speech was of normal rate, rhythm, and volume. Mood was . Affect was appropriate to context and congruent with stated mood. Thought process was linear, logical, and goal-directed. Thought content was negative for SI/HI, delusions, phobias, or obsessive-compulsive thoughts and behaviors. No perceptual disturbances elicited. Patient was AOx4 and attention, concentration, short, and long-term memory was intact during the interview. Fund of knowledge was good. Patient displayed average ability to engage in abstract thought and intellectual reasoning. Judgment is considered good. Insight into symptoms, stressors, and condition is considered fair. Impulse control considered appropriate.

RISK ASSESSMENT:
Suicide risk assessment: After considering variables that influence suicide risk including prior suicide attempts, psychiatric diagnoses that elevates risk, age, gender, family background, interpersonal relationships, physical health, suicide risk variables regarding lethality/access/planning, affective control, degree of hope, family history of completed suicide, degree of willingness to seek help, connection with therapist, and degree of psychosocial support for dealing with current life stressors, potential for substance abuse, current suicide risk is judged to be:
Harm to others:
AWOL risk:

ASSESSMENT:



Axis I:
Axis II: Deferred
Axis III:
Axis IV: Military stressors, chronic condition
Axis V: GAF

PLAN:

Risks and benefits of med(s) discussed. A medication education form has been provided for the prescribed drug(s). Patient agrees with the treatment plan.

 

[nitemagi]

I have an app (psych dx) that also focuses on some of the MSE which can be helpful for med students.

 

[DrPablo]

I use this paper with my counseling students. While it's not specific to psychiatry, I thought you might find it useful.

http://www.unm.edu/~clinic/Procedures/Forms/soap%20notes.pdf

 

[tco]

I use this paper with my counseling students. While it's not specific to psychiatry, I thought you might find it useful.

http://www.unm.edu/~clinic/Procedures/Forms/soap%20notes.pdf

Just glancing at this article, it looks very good. Thank you.

 

[Dr McSexy]

I had used this: http://www.amazon.com/Psychiatry-20...ywords=current+clinical+strategies+psychiatry

Was like $10 at the bookstore.

Basically has a few pages of SOAP notes for psych with various descriptors to use. Order formats, etc. Also gives a brief run-down of some the DSM-IV criteria for various d/o and tx options. Pocket-size and easily carry-able.