{"id":5458,"date":"2015-03-05T11:08:57","date_gmt":"2015-03-05T08:08:57","guid":{"rendered":"http:\/\/seragpsych.com\/wordpress\/?p=5458"},"modified":"2015-03-07T01:43:33","modified_gmt":"2015-03-06T22:43:33","slug":"psychiatric-documentation-soap-is-not-working","status":"publish","type":"post","link":"https:\/\/seragpsych.com\/wordpress\/psychiatric-documentation-soap-is-not-working\/","title":{"rendered":"Psychiatric documentation: Soap is not working?"},"content":{"rendered":"

Soap for follow up notes documentation doesn’t work with psychiatric demands. Promise is working better, do you find it useful?!!!<\/p>\n

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Promise_Better psychiatric documentation<\/a><\/p>\n

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\/Promise_Better-psychiatric-documentation.pdf”>Promise_Better psychiatric documentation<\/p>\n

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Better psychiatric documentation: From SOAP to PROMISE<\/div>\n
Because documentation is an important part of medical practice,<\/div>\n
1<\/div>\n
numerous tools have been<\/div>\n
developed to help physicians<\/div>\n
across all specialties, including the best<\/div>\n
–<\/div>\n
known acronym<\/div>\n
SOAP<\/div>\n
, which stands for<\/div>\n
Subjective, Objective, Assessment, and Plan.<\/div>\n
The<\/div>\n
SOAP<\/div>\n
note has been used in mental health settings,<\/div>\n
2<\/div>\n
although this format may fall short for<\/div>\n
psychiatrists because objective tests are not diagnostic. Also, there\u2019s no clear guidance to document specific<\/div>\n
information, such as behavioral risk asses<\/div>\n
sment.<\/div>\n
The acronym<\/div>\n
PROMISE<\/div>\n
\u2014<\/div>\n
Problems, Resolved, Outcomes, Medications, Instructions, Safety, and<\/div>\n
Education<\/div>\n
\u2014<\/div>\n
may be better suited for psychiatric documentation.<\/div>\n
The<\/div>\n
PROMISE<\/div>\n
note<\/div>\n
provides an easy<\/div>\n
–<\/div>\n
to<\/div>\n
–<\/div>\n
remember method to document specific information that<\/div>\n
might be overlooked in a less detailed format, such as normal findings, adherence and tolerability to<\/div>\n
medications, outcome ratings, and risk assessment.<\/div>\n
The PROM<\/div>\n
ISE note<\/div>\n
provides an easy<\/div>\n
–<\/div>\n
to<\/div>\n
–<\/div>\n
remember method to document specific information that might be<\/div>\n
overlooked<\/div>\n
Problems<\/div>\n
are described as ongoing symptoms, signs, and stressors.<\/div>\n
Resolved<\/div>\n
indicates improvement and normal findings.<\/div>\n
Outcome<\/div>\n
measures include patient or<\/div>\n
clinician rating scales.<\/div>\n
Medications<\/div>\n
documents the effectiveness and tolerability of current and past medications.<\/div>\n
Instructions<\/div>\n
are directives given; the rationale<\/div>\n
\u2014<\/div>\n
cost<\/div>\n
–<\/div>\n
benefit analysis<\/div>\n
\u2014<\/div>\n
can be documented in this section as<\/div>\n
well.<\/div>\n
Safety<\/div>\n
describes a behavio<\/div>\n
ral risk assessment, including demographic, historical, clinical, and<\/div>\n
environmental risk and protective factors regarding suicidal or homicidal behavior.<\/div>\n
Education<\/div>\n
describes the verbal or written material shared with the patient.<\/div>\n<\/div>\n
<\/div>\n<\/div>\n

<\/a><\/p>\n

<\/div>\n
\n
Psychotherapists can use the same template. For them the<\/div>\n
M<\/div>\n
would stand for<\/div>\n
Methods of<\/div>\n
psychotherapy<\/div>\n
practiced in the session.<\/div>\n
For an example of the<\/div>\n
PROMISE<\/div>\n
note used in practice, see the<\/div>\n
Table<\/div>\n
.<\/div>\n
Example of a patient\u2019s PROMISE note<\/div>\n
Problems<\/div>\n
Ongoing depressive symptoms: low mood, negative thinking, low interest level;<\/div>\n
patient has no insurance, pays out of pocket<\/div>\n
Resolved<\/div>\n
Mild improvement in motivation noted; sleeping and concentration both OK;<\/div>\n
continues to work full<\/div>\n
–<\/div>\n
time; spends time with parents<\/div>\n
Outcomes<\/div>\n
Clinical Global Impression<\/div>\n
–<\/div>\n
Severity Scale score: 4; PHQ<\/div>\n
–<\/div>\n
9 depression rating<\/div>\n
scale score: 12\/27, indicating moderat<\/div>\n
e depression (score 1 month ago was<\/div>\n
15\/27; 20% reduction)<\/div>\n
Medications<\/div>\n
Current treatment: citalopram, 20 mg\/d, nortriptyline, 50 mg\/d<\/div>\n
Prior medications: bupropion, citalopram, clomipramine, fluoxetine, MAOIs,<\/div>\n
sertraline, and venlafaxine. Patient\u2019s adhe<\/div>\n
rence to medication is good<\/div>\n
Tolerability issues: sweating, constipation, dry mouth<\/div>\n
Instructions<\/div>\n
Increase both medications (20% improvement noted; recommend increase in<\/div>\n
nortriptyline; patient requests increase in citalopram). Ongoing moderate<\/div>\n
depression; initial side effects may subside<\/div>\n
Safety<\/div>\n
Identified risk or protective factors for suicidal, a<\/div>\n
ggressive, or homicidal<\/div>\n
behavior: chronic depression without remission<\/div>\n
No current SI, HI, SIB, hopelessness, anxiety, agitation, insomnia, substance use,<\/div>\n
psychosis, or interpersonal aggression. No access to weapons. No history of<\/div>\n
suicide attempts. Good sup<\/div>\n
ports. Risk assessment: low<\/div>\n
Education<\/div>\n
1<\/div>\n
.<\/div>\n
What is the main problem? Chronic unremitting depression, some mild side<\/div>\n
effects<\/div>\n
\u2014<\/div>\n
eg, dry mouth, constipation<\/div>\n
2<\/div>\n
.<\/div>\n
What can the patient do about it? Optimize meds; exercise (30 minutes of<\/div>\n
fast walking per day); increase fiber in diet<\/div>\n
3<\/div>\n
.<\/div>\n
Why is it important to do this? Achieve remission (PHQ<\/div>\n
–<\/div>\n
9 score: <4);<\/div>\n
improve tolerability<\/div>\n
HI: homicidal ideation; MAOIs: monoamine<\/div>\n
oxidase inhibitors; PHQ<\/div>\n
–<\/div>\n
9: 9<\/div>\n
–<\/div>\n
Question Patient<\/div>\n
Health Questionnaire; SI: suicidal ideation; SIB: self<\/div>\n
–<\/div>\n
injurious behavior<\/div>\n
Ref:<\/div>\n
:<\/div>\n
Leo<\/div>\n
Bastiaens,<\/div>\n
MD<\/div>\n
Clinical<\/div>\n
Associate<\/div>\n
Professor<\/div>\n
of<\/div>\n
Psychiatry,<\/div>\n
University<\/div>\n
of<\/div>\n
Pittsburgh,<\/div>\n
Pittsburgh,<\/div>\n
PA<\/div>\n
,<\/div>\n
C<\/div>\n
urrent<\/div>\n
psychiatry,<\/div>\n
March<\/div>\n
2013<\/div>\n
Dr. Adel Serag<\/div>\n
…<\/div>\n
DSFH<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

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 […]<\/p>\n","protected":false},"author":1,"featured_media":5465,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[6,5,152,642,458],"tags":[],"class_list":["post-5458","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-6","category-5","category-152","category-mnemonic-slides","category-458","entry"],"_links":{"self":[{"href":"https:\/\/seragpsych.com\/wordpress\/wp-json\/wp\/v2\/posts\/5458","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/seragpsych.com\/wordpress\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/seragpsych.com\/wordpress\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/seragpsych.com\/wordpress\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/seragpsych.com\/wordpress\/wp-json\/wp\/v2\/comments?post=5458"}],"version-history":[{"count":5,"href":"https:\/\/seragpsych.com\/wordpress\/wp-json\/wp\/v2\/posts\/5458\/revisions"}],"predecessor-version":[{"id":5525,"href":"https:\/\/seragpsych.com\/wordpress\/wp-json\/wp\/v2\/posts\/5458\/revisions\/5525"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/seragpsych.com\/wordpress\/wp-json\/wp\/v2\/media\/5465"}],"wp:attachment":[{"href":"https:\/\/seragpsych.com\/wordpress\/wp-json\/wp\/v2\/media?parent=5458"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/seragpsych.com\/wordpress\/wp-json\/wp\/v2\/categories?post=5458"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/seragpsych.com\/wordpress\/wp-json\/wp\/v2\/tags?post=5458"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}