Create Psychiatric Soap Explained for Students (Easy Guide)

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Original Question

Create my Psychiatric SOAP note for me. Include rationale for diagnoses and neurobiological rationale for treatment plan: 30y/o white female seen via telehealth for a follow up. Has history of major depressive disorder, mild recurrent and PMDD. Currently on Sertraline 50mg PO daily. She is married with 2 kids. Reports feeling more anxious lately however not as bad as before starting Sertraline 2 months ago. She works as a school teacher and states it’s been a busy month however, she can not pinpoint the reason for her anxiety. Reports having decreased energy and has not been going on daily walks. Sleep is described as okay. Appetite is decreased when anxious. Has not seen her PCP in over 1 year. Reports anxiety is worse during menstrual period and she has been more irritable and on edge. MSE is normal except for mild fidgeting and anxious mood. Dressed appropriately for season. Speech clear. Denies SI or HI. No delusions or hallucinations. AOX3. Plan is to increase Sertraline to 75mg PO daily. Recommended journaling to document sleep, mood, and triggers to help determine patterns. Recommended follow up with PCP for routine labs such as CBC, Vit D, and Thyroid function. Also recommended taking Magnesium supplement at night and daily MVI for energy. Follow up in 6 weeks.

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