Posted: February 26th, 2023

see below

see below

Initial Psychiatric Interview/SOAP Note Template


Clinical Notes

Informed Consent

Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion)


Verify Patient

Name: MT

DOB: 43 years. (specific DOB not provided

Minor: NA

Accompanied by: NA

Demographic: NA

Gender Identifier Note: male

CC: “ I have difficulty sleeping, impaired concentration, edginess and irritability.”

HPI: matt is a 43 years old male patient who reports to the clinic with complains of irritability, impaired concentration and lack of sleep. He states that he goes from being reserved to explosive in an instant, and his bouts of rage follow him to school. Multiple indicators of excitement emerge in this patient (e.g., difficulty sleeping, impaired concentration, edginess and irritability). The patient reports a history of alcohol and marijuana use, and he admits to using both substances more frequently in the past few weeks. He reports that he has been feeling more irritable and anxious since he increased his substance use..

Pertinent history in record and from patient: Bipolar

During assessment: Patient The patient reports that he has been experiencing difficulty with work and relationships due to his manic symptoms and increased substance use. He reports that he has been having trouble sleeping and has been experiencing racing thoughts.

Patient reports Problems getting asleep and staying asleep, being easily irritated, having trouble concentrating at work, and experiencing severe back and muscular stress are all symptoms of excessive and unmanageable anxiety.

SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors

Allergies: NKDFA.

(medication & food)

Past Medical Hx:

Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury.

Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C.

Surgical history no surgical history reported

Past Psychiatric Hx:

Previous psychiatric diagnoses: none reported.

Describes stable course of illness.

Previous medication trials: none reported.

Safety concerns:

History of Violence
to Self:none reported

History of Violence t
o Others: none reported

Auditory Hallucinations: none reported

Visual Hallucinations: none reported

Mental health treatment history discussed:

History of outpatient treatment: not reported

Previous psychiatric hospitalizations: not reported

Priorsubstance abuse treatment: not reported

Trauma history: Client does not report history of trauma including abuse, domestic violence, witnessing disturbing events.

Substance Use: Client use nicotine/tobacco products.

Client report abuse of or dependence on ETOH, and other illicit drugs.

Current Medications: valproate and bupropion.



Past Psych Med Trials: Patient has had a lifelong problem with irritability

Family Medical Hx: not mentioned

Family Psychiatric Hx:

Substance use- marijuana and nicotine


Psychiatric diagnoses/hospitalization-none

Developmental diagnoses-none

Social History:

Occupational History: currently unemployed. Denies previous occupational hx

Military service History:Denies previous military hx.

Education history: completed HS and vocational certificate

Developmental History: no significant details reported.

(Childhood History include in utero if available)

Legal History: no reported/known legal issues,no reported/known conservator or guardian.

Spiritual/Cultural Considerations: none reported.


Constitutional: No report of fever or weight loss.

Eyes: No report of acute vision changes or eye pain.

ENT: No report of hearing changes or difficulty swallowing.

Cardiac: No report of chest pain, edema or orthopnea.

Respiratory: Denies dyspnea, cough or wheeze.

GI: No report of abdominal pain.

GU: No report of dysuria or hematuria.

Musculoskeletal: No report of joint pain or swelling.

Skin: No report of rash, lesion, abrasions.

Neurologic: No report of seizures, blackout, numbness or focal weakness. Endocrine: No report of polyuria or polydipsia.

Hematologic: No report of blood clots or easy bleeding.

Allergy: No report of hives or allergic reaction.

Reproductive: No report of significant issues. (females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…)


Vital Signs: Stable

BP: 130/86
HR: 74
R: 20
O2: 100
BMI: 24.79
BMI Range: healthy weight

Lab findings WNL
Tox screen: Negative
Alcohol: positive

Physical Exam:
Patient is cooperative and conversant, appears without acute distress, and fully oriented x 3. Patient is dressed appropriately for age and season. Psychomotor activity appears not normal.
Presents with appropriate eye contact,euthymicaffect – full, even,congruent with reported mood of “x”. Speech: spontaneous, normal rate, appropriate volume/tone with no problems expressing self.
TC: no abnormal content elicited, denies suicidal ideation and denieshomicidal ideation. Process appears linear, coherent, goal-directed.
Cognition appears grossly intact with appropriateattention span & concentration and average fund of knowledge.
Judgment appears impaired . Insight appearsfair

The patient is ableto articulate needs, is motivated for compliance and adherence to medication regimen. Patient is willing and able to participate with treatment, disposition, and discharge planning.


DSM5 Diagnosis: with ICD-10 codes

Dx: – Bipolar affective disorder F31.0

Dx: – Post Traumatic Stress Disorder F43.12

Dx: – Nightmare Disorder F51.5

When a person has both bipolar disorder and substance abuse, it can be difficult to manage their symptoms and treatment (Tondo et al., 2021). Substance abuse can make bipolar disorder symptoms worse and make it more challenging to follow a treatment plan. Also, bipolar disorder can lead to impulsive behaviors and poor decision-making, which can lead to substance abuse.

Patient has the ability/capacity appears to respond to psychiatric medications/psychotherapy and appears to understand the need for medications/psychotherapy and is willing to maintain adherent.


(Note some items may only be applicable in the inpatient environment)


Psychiatric. bipolar as per HPI.

Estimated stay 3-5days

Safety Risk/Plan: Patient is found to be stable and has control of behavior. Patient likely poses a minimal risk to self and a minimal risk to others at this time.

Patient denies abnormal perceptions and does not appear to be responding to internal stimuli.

Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic:

No changes to current medication, as listed in chart, at this time

Lithium: The usual maintenance dose ranges from 600-1200 mg/day, orally, and blood levels are typically maintained between 0.6-1.2 mEq/L. Valproic acid: The usual starting dose is 750-1000 mg/day, orally, and the target dose is usually in the range of 1000-3000 mg/day (Gupta, 2020). Education, including health promotion, maintenance, and psychosocial needs. Pharmacologic interventions for the treatment of bipolar disorder and substance abuse involve the use of medication to manage symptoms and reduce the risk of relapse. The specific medications used, as well as the dosage, route, and frequency, will depend on the individual’s specific symptoms and medical history. Mood stabilizers, such as lithium, valproic acid, and carbamazepine, are often used to treat bipolar disorder. These medications work by controlling the manic or hypomanic episodes associated with the disorder. They can also help to prevent or reduce the severity of depressive episodes. The dosage, route, and frequency of these medications will vary depending on the individual’s response and blood level. Atypical antipsychotics, such as olanzapine, quetiapine, and risperidone, can also be used to treat bipolar disorder. These medications work by blocking the action of certain chemicals in the brain that may contribute to manic or hypomanic episodes (Gupta, 2020). They are often used in combination with mood stabilizers to manage symptoms. The dosage, route, and frequency of these medications will vary depending on the individual’s response.

· Discussed current tobacco use. NRT not indicated.

· Safety planning

· Discuss worsening sx and when to contact office or report to ED


Follow-up, including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit 2 weeks

☒>50% time spent counseling/coordination of care.

Time spent in Psychotherapy 18 minutes

Visit lasted 55 minutes



Gupta, J. K. (2020). Bipolar disorder: A major setback in substance abuse. 
Indian Journal of Forensic Medicine & Toxicology, 
14(3), 844-848.

Tolliver, B. K., & Anton, R. F. (2022). Assessment and treatment of mood disorders in the context of substance abuse. 
Dialogues in clinical neuroscience.

Tondo, L., Vázquez, G. H., & Baldessarini, R. J. (2021). Prevention of suicidal behavior in bipolar disorder. 
Bipolar disorders, 
23(1), 14-23.

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