5
Mar
2015
Psychiatric documentation: Soap is not working?
Posted On March 5, 2015
By [email protected]
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Soap for follow up notes documentation doesn’t work with psychiatric demands. Promise is working better, do you find it useful?!!!
Promise_Better psychiatric documentation
/Promise_Better-psychiatric-documentation.pdf”>Promise_Better psychiatric documentation
Better psychiatric documentation: From SOAP to PROMISE
Because documentation is an important part of medical practice,
1
numerous tools have been
developed to help physicians
across all specialties, including the best
–
known acronym
SOAP
, which stands for
Subjective, Objective, Assessment, and Plan.
The
SOAP
note has been used in mental health settings,
2
although this format may fall short for
psychiatrists because objective tests are not diagnostic. Also, there’s no clear guidance to document specific
information, such as behavioral risk asses
sment.
The acronym
PROMISE
—
Problems, Resolved, Outcomes, Medications, Instructions, Safety, and
Education
—
may be better suited for psychiatric documentation.
The
PROMISE
note
provides an easy
–
to
–
remember method to document specific information that
might be overlooked in a less detailed format, such as normal findings, adherence and tolerability to
medications, outcome ratings, and risk assessment.
The PROM
ISE note
provides an easy
–
to
–
remember method to document specific information that might be
overlooked
Problems
are described as ongoing symptoms, signs, and stressors.
Resolved
indicates improvement and normal findings.
Outcome
measures include patient or
clinician rating scales.
Medications
documents the effectiveness and tolerability of current and past medications.
Instructions
are directives given; the rationale
—
cost
–
benefit analysis
—
can be documented in this section as
well.
Safety
describes a behavio
ral risk assessment, including demographic, historical, clinical, and
environmental risk and protective factors regarding suicidal or homicidal behavior.
Education
describes the verbal or written material shared with the patient.
Psychotherapists can use the same template. For them the
M
would stand for
Methods of
psychotherapy
practiced in the session.
For an example of the
PROMISE
note used in practice, see the
Table
.
Example of a patient’s PROMISE note
Problems
Ongoing depressive symptoms: low mood, negative thinking, low interest level;
patient has no insurance, pays out of pocket
Resolved
Mild improvement in motivation noted; sleeping and concentration both OK;
continues to work full
–
time; spends time with parents
Outcomes
Clinical Global Impression
–
Severity Scale score: 4; PHQ
–
9 depression rating
scale score: 12/27, indicating moderat
e depression (score 1 month ago was
15/27; 20% reduction)
Medications
Current treatment: citalopram, 20 mg/d, nortriptyline, 50 mg/d
Prior medications: bupropion, citalopram, clomipramine, fluoxetine, MAOIs,
sertraline, and venlafaxine. Patient’s adhe
rence to medication is good
Tolerability issues: sweating, constipation, dry mouth
Instructions
Increase both medications (20% improvement noted; recommend increase in
nortriptyline; patient requests increase in citalopram). Ongoing moderate
depression; initial side effects may subside
Safety
Identified risk or protective factors for suicidal, a
ggressive, or homicidal
behavior: chronic depression without remission
No current SI, HI, SIB, hopelessness, anxiety, agitation, insomnia, substance use,
psychosis, or interpersonal aggression. No access to weapons. No history of
suicide attempts. Good sup
ports. Risk assessment: low
Education
1
.
What is the main problem? Chronic unremitting depression, some mild side
effects
—
eg, dry mouth, constipation
2
.
What can the patient do about it? Optimize meds; exercise (30 minutes of
fast walking per day); increase fiber in diet
3
.
Why is it important to do this? Achieve remission (PHQ
–
9 score: <4);
improve tolerability
HI: homicidal ideation; MAOIs: monoamine
oxidase inhibitors; PHQ
–
9: 9
–
Question Patient
Health Questionnaire; SI: suicidal ideation; SIB: self
–
injurious behavior
Ref:
:
Leo
Bastiaens,
MD
Clinical
Associate
Professor
of
Psychiatry,
University
of
Pittsburgh,
Pittsburgh,
PA
,
C
urrent
psychiatry,
March
2013
Dr. Adel Serag
…
DSFH
