SOAP Note for Psychiatric Patients: S and O

S - SUBJECTIVE

1. Chief Complaint (CC)

• Patient's primary reason for the visit, verbatim
• e.g., "I haven't slept in 3 days and I feel like I'm losing my mind."

2. History of Present Illness (HPI)

3. Suicidal / Homicidal Ideation (SI/HI) - ALWAYS document

• SI: Presence of ideation? Passive ("I wish I were dead") vs. active ("I want to kill myself")? Plan? Means access? Intent? Previous attempts?
• HI: Thoughts of harming others? Specific person? Plan?
• Document clearly even if denied: "Patient denies SI/HI"

4. Relevant Psychiatric History

• Previous diagnoses, hospitalizations, ECT, past medication trials
• Age of onset, prior episodes, longest period of stability

5. Functional Impact

• How are symptoms affecting work, school, relationships, ADLs?
• "Patient reports missing 3 days of work this week due to inability to get out of bed."

O - OBJECTIVE

Mental Status Examination Components

• Grooming, hygiene, dress (neat, disheveled, bizarre?)
• Nutritional state, apparent age vs. stated age
• Distinguishing features, visible signs of self-harm, tattoos relevant to content
• e.g., "Appears older than stated age, unkempt hair, malodorous, wearing mismatched clothing"

• Eye contact (good, poor, avoidant, intense/staring)
• Gait and posture
• Agitation, restlessness, pacing
• Psychomotor retardation (slowed movement, long latency)
• Abnormal movements: tremors, tardive dyskinesia, tics, stereotypies
• e.g., "Sitting rigidly with arms crossed, poor eye contact, psychomotor retardation noted"

• Cooperative, hostile, guarded, suspicious, evasive, seductive, ingratiating, dramatic
• e.g., "Cooperative but guarded; answered questions with minimal elaboration"

• Rate: Normal, pressured, slow, rapid
• Volume: Normal, loud, whispered, monotone
• Rhythm/fluency: Halting, slurred, stuttering
• Latency: Delayed responses?
• Spontaneity: Initiates conversation or only answers directly?
• e.g., "Speech is slow, low in volume, with increased latency; minimal spontaneous content"

• Patient's own words describing their emotional state (this bridges S and O)
• e.g., "Mood: 'empty, like nothing matters'" - use quotes
• Rate on a scale if preferred: "Patient rates mood 3/10"

• Your observed emotional expression (not what the patient says)
• Range: Full, constricted, blunted, flat
• Quality: Euthymic, dysphoric, anxious, euphoric, irritable, labile
• Appropriateness: Congruent or incongruent with stated mood and thought content
• Reactivity: Responsive to topic changes or fixed?
• e.g., "Affect constricted, dysphoric, congruent with reported mood; reactive to discussion of family"

• How the patient thinks - the structure and flow of thoughts:
  • Goal-directed / linear (normal)
  • Circumstantial (eventually reaches the point but takes detours)
  • Tangential (goes off topic, never returns)
  • Loosening of associations / derailment (jumps between unrelated ideas)
  • Flight of ideas (rapid, connected but uncontrollable - seen in mania)
  • Thought blocking (abrupt stops mid-sentence)
  • Perseveration (repetitive return to same topic)
  • Word salad / incoherent (severe disorganization)
• e.g., "Thought process is circumstantial; patient frequently digresses but eventually answers questions"

• What the patient is actually thinking about:
  • SI/HI (detail here again in the objective observation)
  • Delusions: Fixed false beliefs - paranoid, grandiose, somatic, referential, erotomanic
  • Obsessions / compulsions
  • Phobias
  • Preoccupations (themes the patient keeps returning to)
  • Ideas of reference (belief that external events relate specifically to them)
• e.g., "Patient expresses paranoid ideation - believes coworkers are conspiring to have him fired; denies other delusional content"

• Hallucinations: Auditory (most common in psychosis), visual, olfactory, tactile, gustatory
  • Command hallucinations (do they follow them?)
  • Ego-syntonic vs. ego-dystonic
• Illusions (misinterpretation of real stimuli)
• Derealization / Depersonalization
• e.g., "Patient reports auditory hallucinations - voices telling him he is worthless; denies visual hallucinations"

• Orientation: Person, place, time, situation (A&Ox4)
• Attention/Concentration: Digit span, serial 7s, WORLD backwards
• Memory:
  • Immediate (repeat 3 objects)
  • Short-term (recall 3 objects after 5 minutes)
  • Long-term (personal/historical)
• Fund of knowledge: General information appropriate to education level?
• Abstraction: Proverb interpretation (concrete vs. abstract thinking)
• Formal cognitive screening: MMSE or MoCA score if administered
• e.g., "Alert and oriented x4; attention intact; recalls 2/3 objects at 5 min; abstract thinking intact"

• Patient's awareness and understanding of their illness:
  • Good insight: Acknowledges illness, understands need for treatment
  • Partial insight: Acknowledges some symptoms but minimizes severity
  • Poor insight: Denies illness or need for treatment
• e.g., "Insight poor - patient denies having a psychiatric disorder and attributes symptoms to external circumstances"

• Ability to make sound decisions and understand consequences:
  • Assess via clinical history (recent decisions) or hypothetical scenarios (e.g., "What would you do if you found a sealed, stamped envelope on the street?")
  • Good / Fair / Poor
• e.g., "Judgment impaired - patient stopped psychiatric medications without telling provider; drove while intoxicated last week"

Vitals & Other Objective Data

• Blood pressure, HR, temperature, weight (especially relevant for medication monitoring)
• Lab results if available (lithium level, TSH, CBC for clozapine, metabolic panel)
• Urine drug screen results
• Rating scale scores: PHQ-9, GAD-7, YMRS, PANSS, BPRS, AIMS (for tardive dyskinesia)

Quick Reference Card

S - SUBJECTIVE
├── Chief Complaint (in patient's words)
├── HPI: mood, sleep, appetite, energy, concentration, anhedonia,
│        psychosis, anxiety, stressors, substance use, med adherence
└── SI/HI: ideation, plan, means, intent, history of attempts

O - OBJECTIVE (MSE)
├── Appearance
├── Behavior/Psychomotor
├── Attitude toward examiner
├── Speech (rate, volume, rhythm, latency)
├── Mood (patient's words / self-rating)
├── Affect (range, quality, congruence, reactivity)
├── Thought Process (form/flow)
├── Thought Content (delusions, SI/HI, obsessions)
├── Perceptions (hallucinations, illusions, derealization)
├── Cognition (orientation, attention, memory, abstraction)
├── Insight (good / partial / poor)
├── Judgment (good / fair / poor)
└── Vitals, labs, rating scale scores

Example Snippet