SOAP note example for Nurse or Nurse Practitioner
Subjective
John reports that he is feeling 'tired' and that he 'can't seem to get out of bed in the morning.' John is 'struggling to get to work' and says that he 'constantly finds his mind wandering to negative thoughts.' John stated that his sleep had been broken and he does not wake feeling rested. He reports that he does not feel as though the medication is making any difference and thinks he is getting worse.
Objective
John was unable to come into the practice and so has been seen at home. John's personal hygiene does not appear to be intact; he was unshaven and dressed in track pants and a hooded jumper which is unusual as he typically takes excellent care in his appearance. John appears to be tired; he is pale in complexion and has large circles under his eyes.
John's compliance with his new medication is good, and he appears to have retained his food intake. Weight is stable and unchanged.
Assessment
John presented this morning with low mood and affect. John exhibited speech that was slowed in rate, reduced in volume. His articulation was coherent, and his language skills were intact. His body posture and effect conveyed a depressed mood. John's facial expression and demeanor were of someone who is experiencing major depression. Affect is appropriate and congruent with mood. There are no visible signs of delusions, bizarre behaviors, hallucinations, or any other symptoms of psychotic process. Associations are intact, thinking is logical, and thought content appears to be congruent. Suicidal ideation is denied. Short and long-term memory is intact, as is the ability to abstract and do arithmetic calculations. Insight and judgment are good. No sign of substance use was present.
Plan
Diagnoses: The diagnoses are based on available information and may change as additional information becomes available.
Major depressive disorder, recurrent, severe F33.1 (ICD-10) Active
Link to treatment Plan Problem: Depressed Mood
Problem: Depressed Mood
John's depressed mood has been identified as an active problem requiring ongoing treatment. It is primarily evident through a diagnosis of Major Depressive Disorder.
Long-term goal:
John will develop the ability to recognize and manage his depression.
Short-term goals and interventions:
- Continue to attend weekly sessions with myself
- Continue to titrate up SSRI, fluoxetine
- To walk Jingo once a day
- To use a safety plan if required
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