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Date and TimeS.O.A.P. note template for psychiatrySubjective:Patient states, "some people are coming to get me." History of the patient'sillness: a 60-year-old female patient came into the clinic for an evaluation. The patient is experiencing hallucinations and prefers to stay at her neighbor's house during the daytime and wait for her son at night, claiming that some people are coming to get her. The patient denies any abuse or use of alcohol or other illicit drugs. The patient states that her first symptoms were an extreme shift in mood, behavior, and energy. She explains that one minute, she could be feeling extremely energetic and happy while the next minute, she could be feeling sad, afraid, and depressed. The patient also states that since the onset of her first symptoms more than thirty years ago, her symptoms have worsened over the last few months, and she has been experiencing more frequent episodes of hallucinations compared to the past. The patient's son also states that her mom's symptoms are worse during the day when he is at work, and no one else is at home. The patient also says that she sometimes experiences mild headaches, dizziness, and weakness.Course:Stressors:Collateral information: Two of the patient's close relatives have a history ofhallucinations and extreme mood shifts and have been diagnosed with bipolar disorder. The patient also states that she is often alone at home during the daytime since she only lives with her son, who goes to work every day and comes back at night.Staff observation: the patient's mood is unpredictable, where one moment
she is calm and cooperative while the next moment, she is agitated and restless. The patient has little concentration and is easily forgetful.