Need a total of 20 mini soap notes.
Example provided:
72 y/o W Male
CC: Follow up after medication changes.
S: Patient reports that he is having some anxiety due to his health issues. He also worries about his living situation as he has been living in a hotel. He reports that he does not have any family but has a friend that is trying to help him get a mobile home. He has difficulty sleeping and has taken OTC sleep aids at home. He states he is sleeping an average of 5 hours at night. He states his appetite has been good. He reports that he is motivated and hopeful. Patient is participating in therapy and is cooperative with care in the rehab facility. He denies any suicidal ideation or hallucinations. Patient is tolerating current psych meds without complications noted or reported. NKDA
Current Medications: Buspirone 10mg PO TID, Sertraline 100mg PO daily, Alprazolam 0.5mg PO BID prn for anxiety and Melatonin 5mg PO QHS prn for insomnia.
O: Vitals: Temp – 97.5 BP – 105-67 HR – 81 RR – 18 02 Sat – 100.
A: Insomnia- F51.01
Adjustment disorder with anxiety – F43.22
P: Continue all current psychotropic medications at current dosages and monitor for changes in behavior and/or adverse reactions. Continue journaling as coping mechanisms as patient states it helps with anxiety symptoms. Continue outpatient counseling. Keep track of physical symptoms of anxiety and triggers associated. Follow-up: in 2 weeks or earlier if symptoms worsen.