Provide 4 child/adolescent and 4 adult/geriatric SOAP notes. You can make up the patients and their diagnosis.
Diagnoses: Bipolar Disorder, Anxiety, Depression, Impulse Control, ADHD Practice Management, Diagnosis, and Procedures. Also, enter a brief summary/synopsis of the patient’s visit into the note section. Include: Chief Complaint, Review of Systems, Mental Status Exam, and Plan.
Please don’t forget to enter the following into patient logs Date, Course, Clinical Instructor, Preceptor, Patient number, Client information, Visit information, Practice Management, Diagnosis, and Procedures. Also, enter a brief summary/synopsis of the patient’s visit into the note section.
CC: “ My depression is improving”
HPI: This is a 30 Y/O female who presents to the clinic for medication follow-up. She reports she is doing well on Lexapro 5 mg daily. She denies depression symptoms, anxiety, irritability, and mood swings. She is sleeping 8 hours at night. Her appetite is stable. She denies SI, HI, and AVH. She denies drug and alcohol use. She denies any major stressors.
ROS unremarkable, vitals stable
MSE: She is alert oriented x 4, Mood and Affect euthymic and congruent, judgment/insight fair, well dressed, and appears stated age. No evidence of psychosis appears to be in good physical health.
Plan: Continue Lexapro 5 mg daily, and obtain a full panel of labs including CBC, CMP, TSH, A1C, and Lipid as it is time for the patient’s annual labs and none are in the chart at this time.